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THE DISEASES 



OF 



INFANCY AND CHILDHOOD 



DESIGNED FOR THE USE OF 



STUDENTS AND PRACTITIONERS OF MEDICINE. 



BY 

HENRY KOPLIK, M.D., 

ATTENDING PHYSICIAN TO THE MOUNT SINAI HOSPITAL ; FORMERLY ATTENDING PHYSICIAN 
TO THE GOOD SAMARITAN DISPENSARY, NEW YORK ; EX-PRESIDENT OF THE AMERICAN 
PEDIATRIC SOCIETY; MEMBER OF THE ASSOCIATION OF AMERICAN PHYSI- 
CIANS, AND OF THE NEW YORK ACADEMY OF MEDICINE. 



ILLUSTRATED WITH 169 ENGRAVINGS AND 30 PLATES IN 
COLOR AND MONOCHROME. 




' • ■ » 



LEA BROTHERS & CO., 

NEW YORK AND PHILADELPHIA. 
1902. 



^ 



.. 



A 



THE LIBRARY OF 

CONGRESS, 
Two Copies Reccivcd 

SEP. 16 1902 

COPYRIGHT B*TRY 

ICLA83 XXa NoJ 



cofv b.» 



Entered according to Act of Congress, in the year 1902, by 

LEA BROTHERS & CO., 

In the Office of the Librarian of Congress. All rights reserved. 






WESTCOTT & THOMSON, 
ELECTROTYPERS, PHILADA. 



WILLIAM J. DORNAN, 
PRINTER, PHILADA. 






THIS WORK 

IS INSCRIBED TO MY PRECEPTORS, 

FRANCIS DELAFIELD, M. D., LL.D., 

EMERITUS PROFESSOR OF THE PRACTICE OF MEDICINE IN THE COLLEGE OF 
PHYSICIANS AND SURGEONS, COLUMBIA UNIVERSITY, NEW YORK, 



MATHEW D. MANN, M. D., 

PROFESSOR OF OBSTETRICS AND GYNECOLOGY IN THE UNIVERSITY 
OF BUFFALO, NEW YORK. 



PREFACE. 



During the past decade scientific research in medicine has been 
especially active in the domain of Pediatrics. The literature of the 
subject has grown luxuriantly on both sides of the Atlantic. Much 
of it exists in monographs and special papers, and is thus scattered 
and inaccessible by those conversant with the English language alone. 
The time, therefore, seems opportune for a work which should en- 
deavor to gather and unify the world's best practice in a systematic 
and convenient volume. 

In the following pages, accordingly, American, English, French,. 
German and Italian pediatric science is fully represented. The 
work is, however, not in any sense a compilation. It is based upon 
the author's individual experience and his careful judgment regard- 
ing the work of other pediatrists. He has endeavored to spare his 
readers the labor of deciding between divergent views, and has 
adhered to his purpose of affording the physicians and students 
of his own country a practical guide and text-book. 

He desires to express his gratitude to his publishers for many 

valuable suggestions. 

H. K. 

New York, August, 1902. 



CONTENTS. 



CHAPTER I. 
INFANCY AND CHILDHOOD. 

PAGE 

Definition of infancy and childhood — Morbidity — Mortality — Methods of ex- 
amination : taking a history — The head— The face— Sight — Physical exam- 
ination of the chest: position of the patient; instruments used; methods 
of procedure : palpation ; percussion — The abdomen : inspection ; rectal 
exploration — Examination of the joints— The spine : anatomy ; methods 
of examination — Muscular apparatus and nervous system : form ; atrophy ; 
hypertrophy ; muscle-reflexes ; Babinski's reflex ; Kernig's symptom ; gait 
and walk — Administration of drugs and other methods of therapy— Hydro- 
therapy— Hypodermoclysis— Syringing the nose— Vapor spray and calomel 
inhalations in acute laryngeal disease— Stomach-washing — Gavage — Kectal 
enemata, irrigation, enteroclysis — Hygiene of infancy and childhood : the 
first bath ; the eyes ; the daily bath ; the temperature of the room ; the 
body binder ; clothing ; the skin ; the mouth ; the diaper ; the temper- 
ature ; the breasts of the newborn infant ; open air ; sight ; hearing ; stand- 
ing and walking — Natural feeding of infants and children— Selection 
of a wet-nurse : quantity of milk — The milk is insufficient in quantity — 
Contraindications to nursing — Placing the baby at the breast — The care of 
the breast : caking; sore nipples — Nursing the infant : intervals of nursing ; 
signs of efficient nursing ; increase of weight ; movements of the bowel ; 
signs of insufficient breast-feeding — Composition of human milk : alteration 
of the constituents of mother's milk; influence of food on breast milk 
— Bacteria in breast milk — Methods of analysis of human milk : specific 
gravity; fat; proteids — Microscopical examination of human milk — 
Artificial feeding of infants— Composition of cows' milk ; the increase in 
weight of artificially fed infants — The modification of cows' milk for 
infant feeding : the whey method of dilution and modification — Bacteria in 
cows' milk : pasteurization ; sterilization — Raw milk in infant feeding — 
The nursing bottle — Quantity to be fed to the infant — Amount of breast 
milk consumed by the infant in twenty-four hours— Number of nursings 
daily in artificially fed infants — Composition of the food — Household modi- 
fication of milk for infant feeding— Infant foods — Dextrinized gruels as an 
infant food — Other foods : barley-water ; albumin-water ; peptonized milk ; 
koumyss ; beef-juice; acorn cocoa— Feeding of breast-fed infants and of 
bottle-fed infants after the sixth month — Feeding from the ninth to the 
twelfth month — Feeding from the twelfth to the eighteenth month — Feed- 
ing from the eighteenth month to the end of the second year — Feeding of 
sick infants and children 17-84 



viii CONTENTS. 

CHAPTER II. 

PREMATURE INFANTS— DISEASES OF THE NEWBORN INFANT- 
INJURIES INFLICTED DURING BIRTH. 

PAGE 

Premature infants : management of premature infants ; incubators — Asphyxia 
of the newborn infant — Asphyxia subsequent to birth — Atelectasis of the 
lung— Septic infection of the newborn infant — Diseases of the umbilicus — 
Umbilical Fungus — Infection of the umbilical vessels — Hemorrhage from 
the umbilicus — Idiopathic hemorrhage from the umbilicus — Umbilical 
hernia? — Melaena neonatorum — Acute fatty degeneration of the newborn 
infant — Winckel's disease — Tetanus of the newborn infant — Ophthalmia 
neonatorum — Icterus in the newborn infant — Sclerema — Injuries inflicted 
during birth — Haematoma of the sternomastoid muscle — Cephalhema- 
toma 85-118 

CHAPTER III. 

THE SPECIFIC INFECTIOUS DISEASES. 

The Exanthemata — Scarlet fever — Rotheln — Measles — Varicella — Vaccination 
— Other specific infectious diseases — Typhoid fever — Malarial fever — Influenza 
— Glandular fever — Cerebrospinal meningitis— Posterior basic meningitis 
— Mumps — Pertussis convulsiva — Diphtheria — Diphtheroid— Scrofula — 
Tuberculosis : Pulmonary tuberculosis — Tuberculosis of the peritoneum — 
Simple chronic peritonitis; other forms of tuberculosis (larynx; pleura; 
pericardium) — Abdominal tuberculosis — Tuberculous meningitis — Tubercu- 
losis of the brain — Syphilis : Acquired syphilis — Late hereditary syphilis — 
Congenital or hereditary syphilis 118-277 

CHAPTER IV. 

DISEASES OF THE MOUTH, PHARYNX, AND LARYNX. 

Characteristics of the normal mouth — Dentition: rachitis; syphilis; Hutchin- 
son's teeth ; dental erosions ; microdontism ; dental infantalism ; araor- 
phism — Pathology of dentition — Aphthous stomatitis — Bednar's aphthae — 
Sprue — Toxic stomatitis — Ulcerative stomatitis — Pseudodiphtheritic stoma- 
titis — Gonorrheal infection of the mouth — Noma — The tongue — Congenital 
anomalies of size (macroglossia) — Ringworm of the tongue— Desquamation 
of the epithelium of the tongue— Tongue-swallowing— Tongue-tie — Mal- 
formations of the uvula — Acute retropharyngeal abscess— Retro-cesophageal 
abscess — Adenoid vegetations— The tonsils — Acute follicular amygdalitis — 
Herpes of the tonsils — The la-rynx — Acute catarrhal laryngitis .... 278-304 

CHAPTER V. 

DISEASES OF THE GASTRO-ENTERIC TRACT. 

Physiological and anatomical facts concerning digestion in infants and children 
— The stomach : capacity ; function and motility ; reaction ; marking out 



CONTENTS. ix 

PAGE 

the stomach by percussion — Intestinal ferments — The liver ; the gall 
bladder ; the pancreas ; the bacteria — Characteristics of the stools of infants 
— Acute gastric dyspepsia — Habitual vomiting of infants — Colic — Tympa- 
nites — Hypertrophic pyloric stenosis — Acute gastro-enteritis — Cholera in- 
fantum — Gastro-intestinal atrophy — Acute and subacute enterocolitis — Dys- 
entery : amoebic dysentery — Constipation and mucous disease or mucous 
colitis — Acute intestinal obstruction — Appendicitis : acute ; chronic— The 
rectum: anatomical — Prolapsus ani — Fissure of the anus — Spasm of the 
anus— Proctitis — Polypus of the rectum — Intestinal parasites .... 305-356 



CHAPTER VI. 

DISEASES OF THE RESPIRATORY TRACT. 

General considerations: movements of the chest; fremitus; normal limits of 
the lung ; resiliency of the chest wall ; pulmonary resonance ; dulness ; 
tympanitic resonance; auscultation; the types of breathing; forms of 
dyspnoea — Acute simple bronchitis — Fibrinous or plastic bronchitis — Em- 
physema and chronic bronchitis of the lung — Bronchiectasis, including 
putrid bronchitis — Lobar pneumonia — Bronchopneumonia — Persistent bron- 
chopneumonia — Pleurisy — Dry pleurisy — Pleurisy with effusion and empy- 
ema — Perforating empyema — Hemorrhagic pleurisy — Hemorrhagic empy- 
ema — Subphrenic abscess or pyopneumothorax subphrenicus 357-432 



CHAPTER VII. 
DISEASES OF THE HEART AND PERICARDIUM. 

The heart : position ; size ; apex-beat ; inspection ; palpation ; auscultation ; 
percussion; locating the line of dulness of the left ventricle; the pulse; 
the rapidity ; the rhythm — Congenital heart disease — Stenosis of the pul- 
monary artery, conus or ostium — Open ductus arteriosus or ductus Botalli — 
Congenital defects of the auricular ventricular septum, defects of the auri- 
cular septum, open foramen ovale — Congenital deficiency of the ventricular 
septum (Maladie de Roger) — Acute endocarditis — Septic, ulcerative, or 
malignant endocarditis — Chronic heart disease — Cardiac murmurs — Acci- 
dental cardiac murmurs in infancy and childhood — Myocarditis — Pericar- 
ditis — Adherent pericardium — Hypertrophy and dilatation 433-467 



CHAPTER VIII. 

DISEASES OF THE NERVOUS SYSTEM— METHODS OF DIAGNOSIS. 

Lumbar puncture — Normal cerebrospinal fluid: abnormal conditions; the spe- 
cific gravity ; the gross appearances ; tuberculous meningitis : suppurative 
meningitis ; epidemic and sporadic cerebrospinal meningitis ; chronic hydro- 
cephalus; the sediment; the pressure — The operation of lumbar puncture 
— Infantile convulsions — Hysteria — Tetany — Catalepsy — Myotonia — Con- 



CONTENTS. 

PAGE 

genital stridor of infants — Laryngismus stridulus — Epilepsy — Pavor noc- 
turnus — Chorea — Chorea insaniens — Forms of Tic — Khythmic movements 
of the head associated with nystagmus — Hydrocephalus — Acute hydro- 
cephalus — Chronic internal congenital hydrocephalus — External hydro- 
cephalus — Amaurotic idiocy — Tumors of the brain — Infantile cerebral palsy 
— Facial palsy — Multiple neuritis — Erb's palsy — Hereditary ataxia — Acute 
atrophic paralysis— Juvenile form of progressive muscular atrophy — Lan- 
donzv's form of muscular atrophy — Pseudohypertrophic muscular paralysis 
— Deformities of the skull and spinal canal — Spina bifida 468-532 



CHAPTER IX. 

GENERAL DISEASES. 

Eachitis— Rheumatoid arthritis— Acute articular rheumatism — Rheumatoid af- 
fections — Diabetes mellitus — Diabetes insipidus 533-555 

CHAPTER X. 

DISEASES OF THE LYMPH NODES, DUCTLESS GLANDS, AND 
DISEASES OF THE BLOOD. 

The lymph nodes (infections of ) — Acute adenitis— Chronic lymphadenitis — 
Diseases of the thyroid gland — Cretinism (endemic and sporadic) — Foetal 
rickets or achondroplasia — The thymus gland : landmarks ; weight ; per- 
cussion — Hypertrophy of the thymus — The spleen: anatomical; percus- 
sion ; palpation — Splenic and kidney tumors — The blood — Leading char- 
acteristics in infancy and childhood ; the red blood-cells ; the white blood- 
cells; the haemoglobin; the specific gravity — Anaemia — Simple anaemia — 
Chlorosis — Pseudoleukaemic anaemia of von Jaksch — Leukaemia — Acute 
leukaemia — Chronic leukaemia — Status lymphaticus — Hemorrhagic diathe- 
sis — Simple purpura — Haemophilia — Purpura hemorrhagica — Purpura 
rheumatica — Henoch's purpura : — Pernicious anaemia — Infantile scorbutus 
or scurvy 556-594 



CHAPTER XI. 

DISEASES OF THE BONES. 

General facts concerning diseases of the bones — Osteomyelitis — Otitis in infancy 

and childhood— The mastoid region : general facts ; mastoid disease . . 595-606 

CHAPTER XII. 

DISEASES OF THE LIVER. 

Anatomical facts ; method of examination — Jaundice — Cirrhosis of the liver — 
Abscess of the liver — Fatty degeneration of the liver— Syphilis of the liver 
— Acute yellow atrophy of the liver 607-613 



CONTENTS. XI 

CHAPTER XIII. 
DISEASES OF THE KIDNEYS. 

PAGE 

Anatomical facts — The urine — Cyclic albuminuria— CEdema or hydremia with- 
out kidney lesion — Dysuria — Hematuria — Hemoglobinuria — Renal calculi 
— Acute nephritis — Chronic nephritis — New growths of the kidney — Cysts 
of the kidney — Hydronephrosis — Sarcoma of the kidney — Carcinoma of the 
kidney — Tuberculosis of the kidney — Pyelitis (pyelonephritis) — Peri- 
nephritis and paranephritis — Enuresis nocturna and diurna — Vulvovaginitis 
— Urethritis in male children — Cystitis 614-638 

CHAPTER XIV. 

DISEASES OF THE SKIN. 

General facts — Eczema — Erythema multiforme — Furunculosis — Sudamina 
— Dermatitis exfoliativa — Congenital ichthyosis — Pemphigus neona- 
torum 639-650 



DISEASES OF INFANCY AND CHILDHOOD. 



CHAPTER I. 

INFANCY AXD CHILDHOOD. 

DEFINITION OF INFANCY AND CHILDHOOD. 

Infancy, or the nursing age, is the period of life during which 
the child is at the breast. It extends from birth to the twelfth 
mouth. 

Childhood is the succeeding period, extending to the tenth year. 
In addition, it is customary to divide the period of childhood into 
two parts — the first extending from the end of the first to the fifth 
year ; the second, from the fifth to the tenth year. 

Epstein would include as newborn all infants up to the third 
month. 

MORBIDITY. 

The Newborn Infant. — The diseases of the newborn infant are, 
for the most part, septic in nature, and attack the infant within a 
short time after birth. 

Conditions favor the diseases common at this time of life. The 
skin is not fully formed, is in process of desquamation, and bacteria 
obtain entrance. The umbilicus is an open wound, receptive of 
infection. The mucous membranes of the intestine, mouth, eye, 
and ear are other avenues of entrance for bacteria. There is a ten- 
dency for minor infections to become general at this period. The 
artificially fed infant is, in addition, exposed to the dangers which 
necessarily accompany the introduction into the body of a foreign 
food with its attendant uncleanliness, and is also deprived of the 
protective bodies (antitoxins) contained in the mother's milk. With 
new surroundings, in a new atmosphere, with new appliances for 
maintaining the body-heat (such as the clothes), and with careless 
handling, it is obvious that the newborn infant is particularly sub- 
ject to bacterial diseases. 

2 17 



18 INFANCY AND CHILDHOOD. 

Childhood. — If we study the statistics of any large pediatric 
clinic, it will at once be apparent that up to the tenth year of life 
those diseases which affect the respiratory apparatus form nearly two- 
fifths of the cases. Next in order of frequency are the diseases of 
the digestive tract ; and, lastly, the acute infectious diseases, such as 
the fevers and exanthemata. Of 53,040 cases met with during five 
years in an ambulatory clinic, there were 20,207 cases of diseases 
of the respiratory organs, 17,058 of the gastro-enteric tract, and 
2409 of the acute infectious diseases. If the morbidity is analyzed 
still further, it is seen that in the nursing period intestinal disturb- 
ances are the most frequent. The numerous flora of bacteria and 
their toxins in the intestine of the infant rather predispose to 
infections from that source. These bacteria may invade the mucous 
membrane of the infant, and in certain disturbances of the functions 
of the gut obtain access to the circulation. The respiratory diseases 
become more frequent in the second year, and reach their maximum 
between the second and third year. Constitutional diseases, such as 
rachitis, appear in the second half-year of life, and reach their great- 
est frequency during the period from the tenth to the fifteenth month. 
On the other hand, the acute infectious diseases, such as the exanthe- 
mata, are more common from the fifth to the eighth year. Scarlet 
fever, with its kidney complications, is most frequent at the fourth 
year (Escherich), diminishing at the ninth year. The period ex- 
tending from the second to the fourth year is also notable for the 
frequency of the so-called " filth infections " of Feer. Children 
infect themselves with dirt and dust, at play, at meals, or in their 
intercourse with one another. For this reason, diphtheria as well 
as pertussis and tuberculosis (Escherich) attain their maximum fre- 
quency at this period. 

MORTALITY. 

The mortality of infants is large, and reaches its highest figure 
among the poor of large cities. Among the wealthy, artificial feed- 
ing is resorted to for social reasons ; among the poor, a mother who 
is forced to work is compelled to deny the breast to her child. 
The vast majority of deaths occur among artificially fed infants. 
In England fully two-fifths of the whole number of deaths occur 
before the tenth year, one-fourth occurring before the termination 
of the first year. These figures, given by Williams, correspond 
closely to those of Eross in Germany, and to w r hat is known to be 
true of America. The mode of living among the poor, and the lack 
of complete or of even partial isolation in infectious diseases, tend 
to increase this great mortality among them. 



METHODS OF EXAMINATION. 19 



METHODS OF EXAMINATION. 

Taking a History. — Beginning with a few leading questions, 
the physician inquires as to the sex and age of his patient, the 
number of children in the family, and the use of instruments, such 
as forceps, in the delivery of the infant. The methods of feeding 
the infant from the outset, are inquired into, and the success attend- 
ing these methods. If the patient is in the period of dentition, the 
order of the eruption of the teeth is ascertained. After elicit- 
ing information in regard to any previous illness, the physician 
proceeds to the details of the existing affection. In the greatest 
majority of cases an illness in infants begins with fever, chill, cyano- 
sis, or vomiting. One of these symptoms may be present to the 
exclusion of the others, or they may all be present, or the illness 
may be ushered in with a convulsion. The condition of the patient 
immediately following the initial symptom constitutes the initial 
stage of the illness. Fever or unconsciousness may follow a chill or 
convulsion, or the patient may after the initial symptom develop an 
eruption, cough, dyspnoea, or pain. The fever may subside in a 
few hours, and the temperature return to normal, with a subsequent 
rise, preceded by a chill, cyanosis, or a second convulsion. Older 
children may complain of pain, as adults do. In the case of an 
infant, pain in the chest or abdomen may be indicated by an increase 
in the number of respirations or a sighing or moaning with each 
effort at respiration. 

The vomiting of the initial stage of the illness may not be 
repeated, or it may recur and form a leading feature. The nature 
of the vomited matter is important. It may have an acid reaction 
or odor, or may consist of stomach contents mingled with biliary 
pigment. It may be streaked with blood. In serious continued 
vomiting it may assume a fecal character. Vomiting may occur 
with the ingestion of food or independently of it. 

The condition of the bowels is of importance. The movements 
may be numerous but of normal consistency and odor, or they may 
be diarrhoeal and have abnormal features. The movements may be 
accompanied by tenesmus or prolapse of the gut. The urine of 
sick infants is sometimes not passed for hours. The mother will 
make a note of this fact. The character of the urine is next to be 
ascertained. Its passage may be painful. The urine may stain the 
diaper yellow (jaundice) or red (lithiasis) ; it may contain blood. 
Older children may be required to pass the urine. The quantity is 
more easily estimated in older children than in infants. With the 
latter we should be cautious in drawing conclusions as to the daily 
amount. In taking a history as above, it is essential, while eliciting 
the main features of an illness, not to inquire concerning unimpor- 



20 INFANCY AND CHILDHOOD. 

tant details. The main features of the history should be grasped 
and completed in all their minutiae. 

Taking the Status Praesens. — It often happens that the infant 
or child is asleep during the first portion of the visit. Under that 
condition the respirations and pulse, with the character of each, can 
be noted. The posture during sleep, the expression of the face and 
its contour, the position and behavior of the extremities during rest, 
are of the greatest import. Respiration during rest is more instruc- 
tive than in a condition of unrest and wakefulness. The patient 
should be completely undressed for examination. This is done as a 
routine procedure even in cases of apparently mild illness. Any 
eruption on the skin is thus forced upon the attention of the 
physician. 

The Head. 

The examination of the head should begin with observation of 
its size, whether normal or abnormally small or large. The general 
shape of the head and condition of the bones are of importance in 
reference to the presence or absence of rachitis and areas of 
craniotabes. The manner in which the head is held is noted, as 
bearing on the presence of torticollis. In Pott's disease the head 
is held rigidly on the spine, and in older children supported with 
the hands. Some infants, for instance, amaurotic idiots and those 
suffering from birth-paralyses or diphtheritic paralysis, are unable 
to hold the head upright. In forms of meningitis the head is 
retracted or held rigidly. The fontanelles may be normal, tense, 
depressed, or abnormally prominent ; they may be closed prema- 
turely or open beyond the normal period. The presence of tumors 
underneath the scalp should be noted. The condition of the lymph- 
nodes posterior and anterior to the border of the sternomastoid 
muscle is of clinical importance. 

The Face. 

The expression of the face in a condition of rest, and also when 
the infant or child cries, may enlighten us as to the presence or 
absence of paralyses. These maybe localized, involving the muscles 
of one organ, such as the eye, or the whole side of the face may be 
affected. AVhen the infant is asleep the mouth is normally closed 
and the infant breathes through the nose, the tongue being applied 
to the roof of the mouth. In abnormal states the breathing may be 
noisy ; the cry may be peculiar, as described under Retropharyngeal 
Abscess ; the lips may be cyanosed or the seat of rhagades or erup- 
tions, such as herpes ; the symmetry of the face may be lost, as in 
parotiditis or adenitis, in which there is a swelling of one or both 
sides of the face. 



SIGHT. 21 

Cardiac disease in advanced stages gives a sad and anxious 
expression to the countenance. 

Facial paralysis, either partial or complete, causes a character- 
istic facial expression. If the infant cries, or the child is made to 
smile, one side of the face remains immobile. Even in rest the 
angle of the mouth may be drawn toward the unaffected side of the 
face, as in tuberculous meningitis. 

In nuclear palsy of the congenital variety described by Moebius 
and Schapringer (pleuroplegia) both sides of the face are immobile, 
and the face has a mask-like expression. There are no folds in the 
face either in the acts of laughing or crying. 

Basedow's disease gives a peculiar expression to the face, caused 
by the prominent eyeballs, which are pathognomonic of this disease. 

Hydrocephalus likewise gives a peculiar facial expression. The 
forehead is protuberant and overhanging. The eyeballs are forced 
downward, and the sclera are seen. The face proper is small as 
compared to that part of the head above the eyes. This is due to 
the large size of the cranium. 

Rachitis at times causes a characteristic expression which is 
likely to be confounded with that due to hydrocephalus. In some 
rachitic infants the eyes are prominent and the sclera can be seen 
slightly. The orbital plates of the frontal bone being thin, the 
weight of the brain depresses the eyeball to a very slight degree. 

Exhausting diseases, such as diarrhoea, cause prominence of 
the eyes, giving a very characteristic expression — the so-called 
hydrocephaloid of older writers. 

Congenital syphilis in some cases causes a deformity of the nose, 
which is present at birth. The result is a peculiar angular deformity 
of the normal nasal curve. Looked at sideways, the bony septum 
is depressed ; the cartilaginous septum is still intact. A very acute 
angle between the two results. This is similar to what is seen in 
destructive forms of syphilis later in life. The facial expression is 
characteristic of the disease. 

The angle of the palpebral fissure is altered in conditions 
such as Mongolian idiocy. In this affection it is slightly oblique. 
In paralyses of the ocular muscles the palpebral fissure itself may 
be wider in one eye than in the other. The presence or absence of 
conjunctivitis, keratitis, nystagmus, paralyses of the orbital muscles, 
the condition of the pupils, are all points of importance in deter- 
mining the status prasens. In diseases of the brain or its coverings 
an ophthalmoscopic examination of the fundus oculi should be made. 

Sight. 

In partial or total blindness, not only do the patients not notice 
objects placed in front of them, but there is in addition a vacant 



22 INFANCY AND CHILDHOOD. 

expression or stare. If the blindness is total, the finger will be 
suffered to approach the eye so as to touch the cornea. 

Some infants have a tendency to hold the head to one side. This 
may be due to defective vision or to weakness or spasm of the mus- 
cles of the neck. In cases of defective vision the head assumes a 
normal position if the eyes are not focussed on any object. As soon, 
however, as an effort is made to see, the head is inclined so as to 
bring the planes of vision of the eyes in accord. 

Photophobia is an aversion to light, and is due to a spasm of 
the ocular sphincter in diseases of the conjunctiva or cornea (con- 
junctivitis, corneal ulcer). 

Nystagmus is a series of involuntary movements of the eyeball, 
due to inefficiency of certain muscles, and is met with in conditions 
of corneal opacity, congenital cataract, albinism, infantile amblyopia, 
spasms, nutation or head-nodding, and in nervous states, such as 
amaurotic idiocy. In weakly rachitic infants nystagmus may be 
exhibited around a horizontal or vertical axis of the eyeball, or it 
may show itself in a rotary oscillation of the globe. It is made 
manifest in infants by causing them to focus some bright object, 
held slightly above and to one side of the head. 

Physical Examination of the Chest. 

Position of the Patient. — An infant should be so held for 
examination that the examiner and the patient may be at ease. 
Being undressed, with the thorax exposed, the infant is first held by 
the attendant with its head looking over her shoulder, in which 
position the arms instinctively clasp her neck (Fig. 1). The patient 
so placed does not see the examiner. The spine should be straight, 
so that in percussing the sound is obtained on both sides under the 
same conditions. To examine the chest anteriorly, the infant is 
held looking forward, the anterior aspect of the thorax facing the 
examiner. If it is able to sit up, it may be examined in the sitting 
posture, both anteriorly and posteriorly. 

With older children it is best to make an examination with the 
patient sitting upon a table or chair in a position convenient to the 
examiner. If confined to bed, the child must be examined in bed. 
As a rule, however, it is preferable to have the patient taken out of 
bed into the light. 

Infants and children sometimes try to grasp the instruments of 
the examiner ; gentle suasion will reassure them, force is never 
necessary. 

Instruments Used. — A stethoscope is absolutely essential to the 
proper examination of the chest of an infant or child. This method 
is called mediate examination. We can by its means assure ourselves 
that the whole area of the chest has been carefully investigated. 



PHYSICAL EXAMIXATIOX OF THE CHEST. 



23 



Examination by the ear — the immediate method — is uncertain. A 
small area of bronchopneumonia may easily escape detection in infants 
and children of tender age, in whom the axillae and lateral regions 
of the chest should be carefully searched. Direct application of the 
ear to the chest is resented by infants and children/ and is not a 
convenient procedure for the physician. With the stethoscope he 
can follow the movements of the body of a restless patient. 

Fig. 1. 




Method of holding the infant for the examination of the posterior portion of the chest 

and lungs. 



The best form of stethoscope to employ is the binaural. The 
instrument devised by the author (Fig. 2) has given him the most 
uniform results. A larger stethoscope, such as that employed for 
examination of the adult chest, does not differentiate the variety of 
sounds as well as this small instrument, and may cause pain to a 
restless infant, inasmuch as the chest-piece must be held too rigidly 
and is likely to press painfully against the chest-wall. The old form 
of stethoscope, consisting of a rigid wooden or hard-rubber tube 
applied to the ear, should not be used. If the head is pressed too 



24 INFANCY AND CHILDHOOD. 

forcibly against the instrument, the pressure is communicated to the 
chest and will make the infant unruly. 

A steel tape-measure, marked off into inches and centimetres, is 
convenient for detecting inequalities in the size of the sides of the chest. 

Methods of Procedure. — Inspection. — We learn by inspection 
the shape of the chest and the character of the respiratory move- 
ments ; also, the aspect of the cardiac area, the pulsation of the apex 
of the heart, its force and situation. 

Respiration in infants and children is of the abdominal type. 
The rapidity may be counted by noting the movements of the chest 
or by watching the rise and fall of the epigastric region in the 
recumbent patient. 

The Cardiac Area. — In some infants and children the cardiac 
area may be quite prominent without the presence of any cardiac 
disease. In rachitic infants and children this part of the chest- wall 
may conform to the shape of the heart. There remains even in the 
later childhood of rachitic patients a very slight rotundity or fulness 

Fig. 2. 




Author's form of stethoscope. (Archives Ped., Nov., 1899.) 

of the precordial region. If the chest- wall is quite thin, the precor- 
dial region may normally present a wave of pulsation. All these 
signs may be exaggerated in disease of the heart. The apex-beat is 
normally distinguishable. Its force and area may be increased or 
diminished in disease. The apex-beat may be displaced upward 
and outward, or inward toward the median line (conditions of effu- 
sion in pericardium or pleura). 

Palpation. — Palpation, by laying the palmar surface of the hands 
on the chest, is hardly to be attempted with young infants and 
children. In these subjects the chest is so small that this method 
cannot mark out areas of fremitus or absence of the same. To 
determine its presence, it is more satisfactory to use the internal 
border of the hand, generally the right. The hand is held horizon- 
tally, the internal border pressing firmly against the chest- wall. 
Thus the slightest variations in vibration of the chest-wall can be 
detected. We begin above at the upper border of the chest and 
pass downward, comparing both sides. If the infant or child cries, 
so much the better. If we wish to ascertain the presence of fremitus 



THE ABDOMEN. 25 

in a baby, we may even cause it to cry by a procedure which will be 
described in the chapter on Diseases of the Lungs and Pleura. Older 
children may be asked to count or induced to talk. In infants and 
children fremitus is not so marked or useful a sign as in the adult. 
Normally} it diminishes in intensity as the base of the lung is ap- 
proached. In some children it is detected in the lower part of the 
thorax only by careful examination. It is normally well marked 
along the axillary line ; it is most marked along the mid-regions of the 
chest between the scapula? behind. Anything which separates the lung 
from the chest-wall will diminish or extinguish fremitus. Solidifica- 
tion of lung tissue will cause better conduction and increase it. 

Percussion. — It is not advantageous to use a pleximeter in 
examining infants and children. The index finger of the left hand 
is laid horizontally on the chest with firm pressure. The skin or 
chest-wall and finger are thus made one medium. Percussion is 
performed by making a hammer of the middle finger of the right 
hand. The force used should come from the wrist ; the forearm 
should be immobile. The stroke is expended upon the middle 
phalanx of the finger on the chest-wall, and should be of a tapping 
character, similar to that used in striking the keys of a typewriter ; 
there should not be a pushing motion. The force should not be 
great. A force equal to that necessary in the examination of the 
adult chest would set in vibration all the neighboring chest and 
abdominal organs and cavities, and would not bring out the delicate 
distinctions of sounds necessary to diagnosis. Moreover, to rachitic 
infants and young children a forcible stroke is distinctly painful. 

The Abdomen. 

The abdomen of an infant or child is best examined with the 
patient on a bed or a table covered with a soft blanket. The 
mother's or nurse's knees are not so satisfactory a surface for this 
purpose. The patient should be completely undressed. 

Inspection should include the examination of the skin as to 
color, eruption, presence or absence of oedema, and of the abdomen 
as abnormally rotund or relaxed. In the latter condition we may 
sometimes make out the coils of gut. In diseases which exhaust the 
strength of the patient we distinguish between relaxed and retracted 
abdominal walls. A retracted abdominal wall may be tense and 
incurvated — the so-called boat-shaped abdomen; this is seen in 
meningitis. In some rare forms of septic peritonitis also the abdo- 
men may be retracted. The pain of a colicky attack will cause the 
abdominal walls to be tense although not retracted. In intussuscep- 
tion the coils of gut or even the intestinal tumor may be seen on 
the surface. Ascites distends the abdomen, and when marked the 
rotundity is characteristic, and the skin is tense and shining. 



26 INFANCY AND CHILDHOOD. 

Peritonitis causes tympanitic distention. In perforation of the 
out in typhoid fever or appendicitis the tympanites is accompanied 
at an early stage, as in the adult, by disappearance of the liver dul- 
ness. This sign will aid us more if the liver dulness and flatness 
have been determined accurately in advance of any complications. 

Tumors. — Abdominal tumors give an uneven contour to the 
abdomen. Such tumors are met in diseases of the spleen or kidney 
(sarcoma). Enlargements of the liver and spleen give similar 
appearances. Congenital renal cysts, ovarian tumors, or hydatid cysts 
cause uneven distention of the abdomen. 

Palpation. — We palpate for pain, general or localized, and to 
determine the size and position of the abdominal organs ; for tumor 
whether of or behind the peritoneum, tumors of the liver, kidney, or 
spleen ; enlarged glands behind the peritoneum in the neighborhood 
of the mesentery of the small gut ; polypi in the lumen of the gut ; 
tumors due to appendicitis or intussusception. 

In palpating, we follow a certain routine, and palpate in the 
region of the spleen, then over the liver, and finally in the right 
inguinal region (appendicitis). 

Ascites. — The signs are the same as in the adult. 

Tympanites gives the same signs as in the adult. In newly 
born infants there is in rare cases a congenital weakness of the walls 
of the gut. Any disturbance of the intestinal tract results in immense 
distention, which may be distressing to the patient. Non-inflam- 
matory is distinguished from inflammatory distention (peritonitis) 
by the absence of prostration or fever. There is another form of 
distention which precedes death in severe pneumonia or gastro- 
enteritis. Simple tympanitic distention is seen in rachitic children, 
in whom the lower part of the chest is narrowed and the abdomen 
uniformly protuberant ; in these children the distention is apparently 
increased by the forward curvature of the spine. Percussion gives 
a uniformly tympanitic note all over the abdominal surface, except 
where feces change the note into a dulness. There is no pain or 
only slight general tenderness. 

Pain. — Children may locate the pain felt in pneumonia, pleurisy, 
or pericarditis in the abdomen. The pain may be referred to the 
upper part of the abdomen. The patient may complain of pain 
radiating to the right inguinal region, and thus in lobar pneumonia 
of the lower portion of the right lung mislead us into a consideration 
of the existence of appendicitis. In diffuse peritonitis the pain is 
general, but in localized disease of the appendix the limitation of 
pain can be made out even in young subjects. If we suspect 
appendicitis, it is best to examine every part of the abdomen for 
pain before approaching the right inguinal region. 

In connection with pain and its significance, we may emphasize 
the fact that if the abdomen is relaxed (not retracted), showing the 



EXAMINATION OF THE JOINTS. 27 

grooves due to the muscular parts of the abdorneu — the bellies of 
the recti muscles, the incurvation of the abdomen just below the 
border of the ribs — we may assume the absence of tympanites. In 
such cases peritonitis is rarely present. Pain, which has no definite 
localization iu an abdomen relaxed as above described, may be con- 
sidered as of uo serious import. 

The couditiou of the abdomen in intussusception is described in 
the chapter treating of that subject. 

Polypoid tumors in the lumen of the ascending or descending 
colon may sometimes be distinctly felt in the relaxed abdomen to 
one side of the umbilicus. 

Floating kidney in children has been recently described by 
Coinby. The methods of examination in forms of kidney tumor or 
displacements of this organ are described in the chapter devoted 
to those subjects. 

Rectal Exploration. — This is always carried out in the recum- 
bent position. By rectal examination we may establish the presence 
of an abscess in the right inguinal region or of great swelling of 
the appendix in cases in which it is bound down by adhesions below 
the brim of the pelvis. Rectal exploration is resorted to in all 
cases in which we are led to suspect the presence of an intussuscep- 
tion. In tuberculous peritonitis also, enlarged lymph-nodes may be 
felt through the walls of the rectum. Kidney and ovarian tumors 
can in some cases be felt through the rectum. 

It is not necessary to cause pain in the above procedure. On 
the contrary, rude examination only obscures the case. "We should 
seek every opportunity to become familiar with the normal condi- 
tions externally and per rectum in the vicinity of the right inguinal 
regions in order to be able to diagnose abnormal states. 

Examination of the Joints. 

Affections of the joints are among the most frequent diseases of 
infancy and childhood. The method of examination of the joints 
should be familiar to every physician. If a mother states that her 
baby cries when it is bathed or when it is diapered, we should 
examine the joints. In the newborn infant especially this holds 
true. If there is any limitation of motion, or should the extremi- 
ties be limp, the joints should be inspected. In older children a 
sudden limp or intermittent obscure pain in a joint should receive 
attention at once. 

To examine the joints, the patient should be completely un- 
dressed, and placed on a table. The spontaneous movements of 
the limbs are first observed before any manipulation of them is 
attempted. We may thus observe that one limb is favored by the 
infant, limitation of motion may exist, or there may be a marked 



28 INFANCY AND CHILDHOOD. 

swelling of one joint. The shoulder, elbow, knee, ankle, and other 
joints are systematically examined. This can be done in quite a 
short time if we make it a routine of every physical examination. 
In examining a joint w r e should not forget that when inflamed, it is 
very painful if not gently handled, and that any rude procedure, 
in addition to causing pain, may injure the joint. 

We first inspect the joint to see whether it is swollen, or has 
its normal form, or shows too plainly the prominences of the 
bones entering into its formation. Palpation will tell whether the 
temperature of the surrounding tissues is raised, whether there is 
fluid in the joint or whether the tissues about it are infiltrated. We 
also examine by mild pressure with the fingers the region of the 
junction of the epiphysis and diaphysis for tenderness. 

Mobility is tested by flexing, extending, rotating, abducting, and 
adducting. During such an examination we also note muscular 
spasm. 

Joint-crepitus is a peculiar crackling, rubbing sensation found 
frequently in the joints of infants and children. It is detected by 
placing the palmar surface of the hand upon the joint and moving 
the extremity which enters into its formation. It has been found 
by the writer in children who complained of no definite joint-symp- 
toms. It may, under these conditions, be present in many joints 
of the same patient. Faint crepitus is found in children who have 
had an attack of rheumatism. 

The most common affections to look for about the joints are 
simple luxations ; syphilitic disease ; osteomyelitis of a septic or 
infectious nature; scurvy of the joints or epiphyses in the vicinity 
of the joint; rheumatism, simple acute or chronic, and gonorrhoeal; 
tuberculous joints, especially the hip ; paralyses (deltoid) of muscles 
about a joint ; deformities, as in congenital coxa vara. 

The Spine. 

Anatomy. — The spinal column of the newborn infant is practi- 
cally devoid of natural fixed curves. Fehling found that there w r as 
an almost imperceptible curve backward (kyphosis) in the dorsal 
region and a slight lordosis in the lower lumbar region. The latter 
curve was more marked when the extremities of the infant were 
extended. The fixed curves seen in the cervical dorsal and lumbar 
regions later in life begin to form in the first year. They are fully 
fixed by the seventh year. 

Method of Examination. — The purpose of examination is prin- 
cipally to discover abnormal curvatures and to test the pliability of 
the vertebral column. In other words, we examine for rigidity due 
to disease (Pott's). The patient is undressed and made to stand 
erect. The index finger is passed down the vertebral spinous proc- 



THE SPIXE. 



29 



esses, and the lines of these processes thus marked out. Any ab- 
normal curve is thus made apparent. Painful areas are detected by 
pressure or tapping along the spinous processes. If deformity is 



Fig. 3. 




t&LZJtpity, 



Method of testing mobility and pliability of the spine. 

present, it is important to decide whether this is permanent and 
combined with muscular spasm (Pott's), or due to rachitis. For 



Fief. 4. 




Method of testing for psoas spasm. 



this purpose the patient is placed on the examining table face down- 
ward. The examiner grasps both lower extremities at the ankles 
(Fig. 3). The palmar surface of the left hand is laid firmly on 



30 JXFANCY AND CHILDHOOD. 

the junction of the cervical and dorsal spine. The extremities are 
now raised and hyperextended with the right hand. If the spine 
is supple and normal, it will curve backward as the pelvis is raised 
toward the vertical. If there is deformity due to Pott's disease, 
this will persist. Deformity due to rachitis will disappear under 
this manipulation. If the left hand is laid on the lumbar region 
and the above hyperextension gently carried out, first flexing the 
legs hack at a right angle and then lifting them vertically, a distinct 
spasm of the muscles is felt (psoas spasm) (Fig. 4). Spinal rigidity 
is also made apparent by causing the child to pick up some object 
from the floor. Under conditions of disease the patient will hold the 
spine rigid in picking up the object. The hips and knees are bent, 
but not the spine. To test the rigidity in the beginning of menin- 
gitis, the head is raised as the patient lies recumbent. In meningitis 
the rigidity is such that the whole trunk can be raised by placing 
the palm underneath the occiput and gently raising the head. 

Muscular Apparatus and Nervous System. 

Form. — Atrophy of muscle is seen in any disease which affects 
the trophic centres of muscle in the cord. Such diseases are polio- 
myelitis, and neuritis following traumatism, diphtheria, measles, or 
any infectious disease. Atrophy is seen in joint-affections, especially 
about the hip. In the latter case, not only disuse, but a true reflex 
trophic disturbance is the cause of the atrophy. 

Hypertrophy of muscle is seen in cases of isolated congenital 
hypertrophy of one limb, and also in pseudohypertrophic paralysis. In 
all cases of change of volume of a muscle we first inspect the affected 
limb and compare it with that of the opposite side if the disease is 
unilateral. The diseased limb is measured in its circumference and 
compared with the corresponding healthy limb. 

Muscle-reflexes. — We shall take up only that aspect of the 
subject which should concern the practitioner in his examination of 
infants and children. The minutiae of electrical muscle and nerve 
reactions may be gleaned from works treating of such matters in 
detail. 

The most common deep reflex is that of the patellar tendon. It 
is obtained by placing the infant in a recumbent position, supporting 
the thigh by placing the left hand beneath it, and raising it above 
the level of the body. When the muscles are relaxed, tap the patellar 
tendon sharply with the middle finger of the right hand. The 
pr< ieedure is similar to that employed in percussion of the chest. Both 
limbs are examined in the same manner. Children who can sit are 
placed on a table with their lower extremities dependent. When 
the attention of the patient is fixed upon some object tap the tendon, 
sharply. A percussion-hammer is not necessary. 



MUSCULAR APPARATUS AXD NERVOUS SYSTEM 31 

In diseases of the gray matter and of the posterior columns of 
the cord with trophic disturbance of the nerves (poliomyelitis, neu- 
ritis, Landry's paralysis, diphtheritic paralysis) the patellar reflex is 
diminished or absent. 

In brain tumor and in affections of the lateral columns of the 
cord (multiple sclerosis, spastic disease) the reflex is increased. 

The reflex is unimpaired in cerebral palsy, Friedreich's ataxia, 
and in cases of idiocy. 

Babinski's reflex is a plantar phenomenon found in some forms 
of meningitis (tuberculous), and in diseases in which there is irrita- 
tion or involvement of the pyramidal tracts. On irritating the 
plantar surface of the foot with the tip of the index finger there is a 
vigorous hyperextension of the great toe (see Fig. 70). Morse has 
shown that this reflex cannot be relied upon in children under the 
second year. I have had abundant opportunity to confirm this 
observation. As a differential diagnostic sign, the Babinski reflex is 
of little value, although I have observed it to be present more fre- 
quently in the tuberculous forms of meningitis than in the pyogenic 
varieties. 

Kernig's symptom is found in children suffering from any form 
of meningitis and in diseases such as typhoid fever with cerebral 
symptoms. The sign has the same characteristics as in the adult. 
In infants under one year the tendency to flex the thigh in the sitting 
posture is normal. In these subjects, therefore, the presence or 
absence of this sign possesses no significance. 

Gait or Walk. — The child is undressed, so that the feet and toes 
are exposed, and is caused to walk to and fro in front of the physi- 
cian. The gait in disease may be ataxic, spastic, paretic, or wab- 
bling. 

Ataxic gait is seen in children suffering from Friedreich's ataxia, 
or from tumor involving the motor centres for the lower extremi- 
ties. The gait is uncertain ; patients walk as if inebriated, with 
the feet wide apart. Incoordination of movement is character- 
istic of all these cases. AVe must in all cases distinguish between 
simple muscular weakness, as in pseudohypertrophic paralysis, 
and convalescence from acute disease, such as fevers, and a weakness 
combined with a palpable defect in the power of coordinate action. 
In cases of cerebral disease, as a rule, there is lack of coordination 
elsewhere, as in the muscles of the upper extremities. In these 
cases the coordination is tested in older children by telling the 
patient to close the eyes, and directing him to touch the tip of the 
nose with the index finger of the right hand several times in succes- 
sion. In cases of ataxia there will be great uncertainty in carrying 
out this manoeuvre. In diphtheric paralysis there may be combined 
with a real weakness, ataxia or incoordinate movement. If we 
remember that in these cases there is a neuritis, with consequent 



32 INFANCY AND CHILDHOOD. 

atrophy of muscle and loss of reflex, we shall not commit the error 
of overlooking the paralysis in our desire to account for the condi- 
tion present as a simple muscular weakness the result of the illness. 
In these eases there may also be paralyses of the trunk muscles, 
causing inability to assume the upright posture. In ataxia caused 
by cerebral tumor there is in certain cases a crossed hemiplegia 
(pons tumor), with foot-clonus and paralysis of ocular muscles, 
which aid in the diagnosis. 

Cerebellar Titubation. — In cerebellar tumor, which is the variety 
most common in children, there are at the outset, in most cases, 
disturbances of the gait or ataxia. The patients walk in an uncer- 
tain manner, generally staggering to one side. In severe forms of 
this disease the patients will fall to one side if not protected. The 
cases thus far recorded all show early involvement of the optic, 
auditory, and other cranial nerves, abducens paralysis, with symp- 
toms of vertigo. 

Spastic Walk. — This walk is so characteristic as not to be easily 
mistaken for anything else. It is found in all forms of spastic 
paraplegia, congenital or acquired. There is not only actual spasm, 
but also weakness of muscle. There are other phenomena of 
nervous disturbance, such as increased patellar reflex and foot- 
clonus. The patient seems to drag his legs in walking. Each 
extremity is brought rigidly forward, the toes scraping the ground. 
The muscles may or may not be well nourished. Electrical con- 
tractility may or may not be increased. The children may walk 
cross-legged (Gowers). At first there is inability to walk ; later in 
childhood locomotion is possible. In certain forms the spasm of 
the extremities is so great as to keep them in constant extension at 
the knee ; flexion in these cases can only be attained with great 
expenditure of force. 

In infants and children who cannot walk and are the subjects 
of spastic paraplegia the characteristic position of the lower extremi- 
ties may be made apparent by supporting the patient on the feet. 
In all of these cases, as soon as the toes touch the ground the reflex 
produces the characteristic extension of the limbs, with the toes or 
ball of the foot on the ground and the heel raised. 

In very young infants who are the subjects of amaurotic idiocy 
the spastic phenomena are sometimes very marked. In these cases 
there are other symptoms, such as amaurosis and inability to hold 
the head upright ; the presence of the Tay-Kingdon spot in the 
fundus of the eye aid in the diagnosis. 

Limping Gait. — Joint-affections cause simply a limping gait ; a 
study of the joint, as described elsewhere, will aid the diagnosis. 

Infantile paralysis, or cerebral palsy, at the outset causes the 
characteristic dragging of the extremity if the paralysis is not com- 
plete. Infants in whom there is a complete loss of power in one or 



ADMINISTRATION OF DRUGS, AND METHODS OF THERAPY. 33 

both lower extremities give a history as follows : The infant may 
have been able to walk or stand ; the attack suddenly deprives it of 
the power of motion. There is a limp extremity on one or the 
other side, with rapid atrophy of muscle and loss of reflex. In cere- 
bral palsy there is no atrophy and the tendon reflex is present. 

The methods of examining the mouth and special organs will 
be taken up in the chapters devoted to their diseases. 



THE ADMINISTRATION OF DRUGS, AND OTHER 
METHODS OF THERAPY. 

Children should receive drugs in an agreeable form, although 
some may take nauseous drugs with apparent indifference. Bulky 
mixtures or drugs which are apt to upset the stomach should 
not be prescribed. The author recently saw a severe enterocolitis 
set up by a cough mixture containing antimony. Drugs should not 
be administered in pill form to infants or children. Tablets are 
a ready means of administering certain drugs. They can be 
crushed and given in a teaspoonful of some indifferent fluid. 
Powders are also easily taken. They are put in a spoon, some 
fluid added to form a mixture, which is then administered. Quinine 
is given either in syrup of verba santa or in chocolate powder 
and water ; or the child is given a piece of chocolate to eat, and 
then is caused to take the quinine immediately afterward. A child 
should never be forced to take a medicine. Much harm is done in 
this way. Certain drugs, such as opium in the form of the simple 
tincture or morphine, are not given to children under the age of 
two years. Atropine, of late advocated in cholera infantum, should 
not be given to infants and young children. They bear this drug 
badly. Jaborandi is badly borne, as is also apomorphine. Camphor 
is a very good cardiac stimulant. It is useful in collapse, but must 
be given cautiously in cases in which there is diarrhoea. In the 
latter disease the camphor is apt to irritate the stomach and gut. 
The coal-tar series, such as antipyrin, antifebrin, and phenacetin, 
are powerful depressants. In those cases of fever in which it is not 
possible to give baths to lower the temperature we are sometimes 
forced to administer these drugs. It is then well to combine with 
them some caffeiue. 

If a child or an infant refuses to take a drug, it may be put 
in a teaspoon, the spoon held horizontally to the lips, and when the 
mouth is opened the spoon carried far back into the mouth and 
tilted. The spoon is held in the mouth until the act of swallowing, 
which must inevitably take place, is completed ; the spoon is then 
withdrawn. If this manreuvre is thus carried out, the fluid will not 



34 INFANCY AND CHILDHOOD. 

be rejected. Holding the nostril closed, and thus forcing the child to 
open the mouth, is bad practice. Patience and suasion can accom- 
plish as much in most cases. 

Digitalis is not given continuously, but is administered for two 
or three days, and when the pulse begins to show signs of lessened 
frequency its administration is suspended. Alcohol is well borne bv 
children. I do not hesitate to administer it in cases of nephritis 
if the heart is weak. In the gastro-enteritis of nurslings the 
stomach is very intolerant of alcohol. It should not be given except 
in very severe cases with great prostration, as the vomiting is apt to 
be aggravated. Much has been written concerning antipyresis and 
antipyretics in the treatment of the diseases of infancy and child- 
hood. The young practitioner can feel assured that high tempera- 
tures are well borne by infants and children. A temperature of 
106.5° F. (41.3° C.) in an adult, although of short duration, would 
cause great alarm, and rightly so. On the other hand, such a tem- 
perature in an infant or child does not necessarily threaten life, nor 
is it incompatible with recovery. A convulsion in some children is 
the direct result of a rise of temperature. Such a convulsion will 
not necessarily lead to others nor to epilepsy. The heart and kidneys 
Ijear long-continued high temperature well in comparison with those 
of the adult. The most trivial causes will cause a rise of a degree 
or two in the temperature of an infant or a child. Taking all these 
idiosyncrasies into consideration, it may easily be understood by 
the student and young practitioner why it is essential that methods 
of therapy should be modified before they can be applied to infants 
and children. A reduction of temperature from 104° to 102° F., 
even if it can be accomplished by a coal-tar derivative, does not 
cure the patient. Some diseases, such as measles, scarlet fever, 
pneumonia, and a host of others, run a course of high and low 
temperatures extending over a certain space of time. If an infant 
or child is attacked with convulsions following every acute rise of 
temperature, the parents should be warned of this fact. In these 
cases, as soon as a rise of temperature is noted, it should be com- 
bated by every means in our power. Reduction of temperature in 
such children at the outset of a disease is of the highest utility. 
It saves the nervous system from the shock of a convulsion. 
Hydrotherapy is, as a rule, the safest and most satisfactory antipy- 
retic measure at our disposal. 

The dosage of drugs for infants and children has received much 
attention. In practice we judge more by the action of a remedy 
than the quantity administered. The initial dose should be small. 
Infants under a year receive -^th of the adult dose, and at the age 
of one year T yth of the adult dose is safe. At the fifth year |th, 
and at the tenth year \ the adult dose is the rule. These figures 
are not absolute. Nitroglycerin if given in doses of less than 



HYDROTHERAPY. 35 

^4-g-th of a grain has scarcely any effect on children five years 
of age. On the other hand, strychnine may be safely given in 
quantities of -^-g-th. of a grain to infants, and y^g-th °^ a g ram to 
children two to three years of age. It will be seen that if the 
hard-and-fast rule of division of doses according to age were fol- 
lowed, these drugs would necessarily be given in much smaller dose, 
and their action would be correspondingly inefficient. 

Hypodermic administration of drugs to infants and children pre- 
sents nothing peculiar, as compared with the same method applied 
to adults. 

Hydrotherapy. 

The practice of hydrotherapy as applied to the adult must be 
somewhat modified before it can be carried out with the infant or 
the child. The reason for this is that the infant or child does not 
react so readily and cannot bear sudden changes of temperature so 
well as the adult. 

The Sponge Bath. — A rubber sheet is placed on the crib, and 
over this one layer of a small blanket ; the patient is then placed 
nude on this blanket and covered with another blanket. There is 
thus no undue exposure. A small basin of water at 80° to 85° F., 
with a dash of alcohol, is now brought alongside of the crib. 
TTith a small sponge or piece of soft folded linen the parts of the 
patient are sponged ; first one arm, then the other, then the trunk, 
and finally the loAver extremities. As each part is exposed, the rest 
of the body is kept covered. This procedure is repeated until the 
body has been sponged for five or ten minutes. This method of 
hydrotherapy is especially suitable in acute rises of temperature of 
short duration and in mild cases of continued fever in which the 
temperature does not rise high. 

Cold Chest Compress. — Three layers of linen are cut so that 
they will envelop the trunk from the clavicles to the umbilicus. The 
general shape should be that of a shirt deprived of arms and open 
at the sides. On the outside of this linen compress there should be 
a compress of Shaker flannel cut in a similar manner. The com- 
press of linen is moistened with water at 80° to 85° F. With 
robust children the water may be at 70° F. The compress is wrung 
out and applied so that the neck, shoulders, and chest are covered 
as with a shirt. The flannel is now applied to the outside. The 
compress is moistened every hour with water at 70° to 85° F. and 
re-covered with the flannel. 

The cold pack is not so useful in the treatment of the febrile 
conditions of childhood. The method is similar to that followed 
with the adult, with the exception that the sheet is moistened with 
water at 80° to 85° F. In other cases the patient, after being 
wrapped in such a sheet, is rubbed by the attendant with ice on the 



36 INFANCY AND CHILDHOOD. 

outside of the sheet. The author has had no extensive experience 
with this method. 

The Full Bath. — The full bath, as advocated by Brand, is 
seldom carried out in the treatment of children. Children struggle 
against the bath, and if the temperature is too low, they become so 
depressed that it is difficult to rouse them. I therefore place chil- 
dren with typhoid fever, or pneumonia, or scarlet fever in a bath at 
100° to 105° F., and lower the temperature to 80° or 85° F., 
applying friction to the body constantly. After five or ten minutes 
the patients are taken out of the bath and rubbed dry. Warm- 
water bottles are applied to hands and feet. 

In conditions of delirium and coma with a high temperature, in 
which the heart is weak, I have given baths at a temperature of 
105° to 108° F. The cases in which these baths are indicated are 
those in which any application of cold water causes cyanosis and 
collapse. I have seen infants suffering from bronchopneumonia, 
with high temperatures, in a condition resembling a rigor after a 
bath at 85° F. With these infants the warm bath acts as a cardiac 
stimulant and quiets the nervous symptoms. 

Hypodermoclysis. 

Hypodermoclysis is the injection into the subcutaneous tissue of 
either a 0.6 per cent, salt solution or the normal salt solution of 
Cantani (sodium chloride, 4 parts ; sodium carbonate, 3 parts ; 
water, 1000 parts). It is indicated in infants suffering from 
cholera infantum and in other exhausting states. Monti, who was 
the first to apply this mode of therapy to the infant, injects 100 to 
200 c.c. at a time. Epstein showed that smaller quantities — 10 to 
40 c.c. — are more beneficial and more quickly absorbed. Expe- 
rience teaches that large quantities of fluid injected subcutaneously 
cause extensive blood extravasations in exhausted infants and much 
subsequent pain. The solutions used should be freshly prepared and 
sterilized. Welch has reported cases of infection with Bacillus 
aerogenes capsulatus following hypodermoclysis. I have had one 
case, although every precaution was taken to avoid infection. 

A large antitoxin syringe, holding 20 c.c, is used. It should 
be carefully sterilized. 

From 20 to 30 c.c. of the solution are injected two or three times 
daily into the subcutaneous tissue of the lumbar region or abdo- 
men. Monti injects into the subcutaneous tissue of the abdomen. 
Massage should not be performed after injection, as it is very pain- 
ful and causes hemorrhages. The puncture wound is covered with 
a piece of sterile gauze. The main point is to inject small quantities 
of the solution at intervals of from four to six hours, and watch the 
effect. The action is that of a stimulant to the heart and the 



SYEIXGIXG THE NOSE. 



37 



processes of resorption. Epstein showed that within a few hours 
after injection of salt solution the proportion of haemoglobin and 
red blood-cells was reduced. As salt solution has a dissolving 
effect on the red blood-cells, the injection of large quantities of 
the solution may be harmful. 



Fig. 5. 



Syringing the Nose. 

Instruments. — The best form of 
syringe for this purpose is an olive- 
tipped glass syringe. Some forms 

i «,i n, l i ,• Nasal svringe. Correct shape. 

are made with a soft-rubber tip. 

The tip should be blunt, lest the nares be injured (Fig. 5). 

Fig. 6. 




tf-J5ic/ t <ys 



Method of syringing the nose in the upright posture. 

The solution used is generally a normal salt solution. 

Method. — The infant or child is wrapped in a sheet or blanket, 



38 



INFANCY AND CHILDHOOD. 



and held in the lap of a nurse, who holds a pus basin beneath its 
chin. The operator stands behind the patient. The syringe is held 
horizontally to the floor of the nares and the solution slowly injected 
into the nostril (Fig. 6). If successfully performed, the procedure 
results in the solution's coming out of the other nostril. There is 
no danger in the manoeuvre if carefully carried out. If the infant 
is too weak, the nares may be syringed with the patient in bed in 
the recumbent posture. The nurse stands at one side, and the head 
is placed on the side, the pus basin beneath the nose, as shown in 
Fig. 7. A rubber fountain-syringe may be used in the same manner. 

Fig. 7. 




Method of syringing the nose in the recumbent posture. 

Here also the position of the syringe is horizontal to the floor of the 
nares. The syringe should be thoroughly boiled before and after 
using. An old syringe should never be used, no matter how care- 
fully it has been sterilized. 

Vapor Spray ; Calomel Inhalations in Acute Laryngeal Disease. 

With infants and children the spray is not so useful an agent as 
steam vapor impregnated with balsams or turpentine, and combined 
at times with inhalations of the fumes of sublimed calomel. The 
spray cannot, as a rule, be used locally except with the most tract- 
able children. With infants its use is not feasible. 

The vapor of steam impregnated with balsams or turpentine is 
very useful in all forms of acute laryngitis in which there is no 
bronchitis. I dispense with steam vapor if bronchitis is present. 
The mode of application in catarrhal or membranous croup is as 
follows : The crib is covered with a sheet suspended from four 



STOMACH WASHING. 



39 



upright poles fastened to the corners of the crib. A tent is thus 
formed. The croup kettle is placed at one side of the crib, in such a 
manner that the steam vapor escapes into the improvised tent. The 
vapor is medicated by placing in the 
kettle a teaspoonful of turpentine or 
thymol. This will be readily vapor- 
ized. No special apparatus has any 
advantage over the ordinary croup 
kettle. If calomel sublimations are 
to be given, they should be combined 
with the steam vapor. Ten grains of 
calomel are placed in a spoon held 
over an ordinary candle, and the 
fumes led under the tent, the air of 
which is impregnated with steam va- 
por. The special devices sold for the 
sublimation of calomel may be used, 
but possess no advantage over the 
method described above (Fig. 8). 
Calomel sublimations are exceedingly 
irritating, but they relieve the patient 
very promptly. They may be con- 
tinued for forty-eight hours at intervals of two hours, without 
fear of salivation. 




Sublimer for calomel inhalation. 



Stomach Washing. 

One of the most valuable additions to our therapeutic armament 
within recent years is stomach washing in case of the nursing infant. 
No improvement has been made upon the method as first proposed 
by Epstein. The cases in which it is indicated are mentioned in 
another part of this work. The procedure is easiest of application to 
nurslings in whom there are no teeth or in whom very few teeth 
have erupted. With these subjects there is no danger of the catheter's 
being bitten, and there is no necessity of using a gag. With older 
children, however, a gag must be used when stomach washing is 
attempted. The Denhardt gag of the O'Dwyer set of intubating 
instruments is most suitable for this purpose. 

Indications. — Washing out the stomach is principally indicated 
in the acute gastro-enteritis of the summer months. It is not bottle- 
fed infants alone that are attacked, but even breast-fed infants may 
be thus affected. The winter months also furnish their quota of 
these cases. One vomiting spell, as it is called, does not require 
attention. If, however, on suspension of the bottle or breast, vom- 
iting continues and becomes uncontrollable, we proceed to stomach 
irrigation. Another indication is the so-called chronic dyspeptic 



40 



IXFAXCY AXD CHILDHOOD. 



vomiting. Those who advocate this method of treatment in these 
cases forget that, above all, the food is at fault, and must be regulated 
and modified. I do not favor washing the stomach in these cases. 

One washing is, as a rule, sufficient. I have rarely had to 
repeat it. If vomiting persists after the first washing, it is well to 
look for other conditions than gastro-enteritis as the cause of the 
vomiting, such as intussusception. 

Acute drug poisoning or ingestion of any irritating fluid is quickly 
relieved by stomach washing. I have washed out many children 
who had been given an overdose of paregoric, or who had taken 
Paris green, turpentine, or other drug. If, as sometimes happens, a 
child accidentally swallows a caustic alkali, we should not introduce 
the tube into the oesophagus or stomach. 

Method. — A four-ounce funnel, a piece of rubber tubing two and 

Fig. 9. 






Apparatus for washing out the stomach. 



a half feet long, and a No. 14 rubber catheter are the instruments 
necessary. The rubber tubing is attached to the funnel, and by 
means of a piece of glass tubing to the catheter, as in Fig. 9. 
About a quart of normal saline solution is needed. The temperature 



< 




GAVAGE. 41 

of the water should be at least 100° F. The operator needs one 
assistant. The infant is completely undressed, and is then wrapped 
in a blanket, the diaper having first been applied. The hands are 
tucked in with safety-pins. The infant having been laid recumbent 
on a table, the operator, standing on the right, introduces his left 
index finger into the mouth and depresses the tongue (Plate I.). 
The catheter, moistened with water, is now introduced and passed 
backward. With gentle urging the catheter passes easily into the 
oesophagus. There is no likelihood of the catheter's passing into the 
larynx and trachea. About six inches of the catheter are intro- 
duced. The funnel is depressed and the stomach contents are first 
allowed to flow out. The funnel is then raised about two feet 
above the patient, and the assistant slowly pours the saline solution 
into the funnel, the fluid flowing into the stomach. Before the 
funnel is completely emptied, it is lowered and the stomach contents 
siphoned out. This operation is repeated several times, until the 
water returns quite clear. If during the stomach washing the fluid 
should be ejected from the stomach in the act of vomiting, it will 
easily flow out of the mouth if the infant is recumbent. There is 
not the slightest danger of aspiration of the fluid into the trachea. 
I think the recumbent position is superior to the sitting posture advo- 
cated by some clinicians. A young infant is unable to sit up of its 
own accord. The introduction of the tube is not so easy for the 
infant in the sitting posture as in the recumbent position. The tube 
being introduced, the stomach contents sometimes refuse to flow out 
because mucus and food particles obstruct the lumen of the catheter. 
In such cases the catheter is withdrawn, and washed out. The cathe- 
ter is then pinched with the fingers in such a manner that some of the 
water or washing solution remains in the catheter. It is then intro- 
duced into the stomach. In this way the catheter, being filled with 
fluid, mucus and food cannot obstruct the lumen of the tube before 
siphonage is begun. Fluid can then readily be introduced into the 
stomach. These difficulties occur in cases in which there is a large 
amount of mucus in the stomach. The finger should always be 
retained in the mouth. By grasping the catheter with the thumb 
and index finger of the right hand, prying open the mouth at the 
same time, we prevent pressure on the catheter during the washing. 
If the infant has upper and lower incisors, the catheter must be held 
at one side of the mouth and the mouth kept open by means of the 
index finger held in the angle of the mouth. The method described 
above has been followed by me for years. I have never had an 
accident. 

Gavage. 

Gavage is a method of forced feeding by means of the stomach- 
tube. I have not practised this method of feeding infants. Older 



4t2 INFANCY AND CHILDHOOD. 

children suffering from pneumonia or typhoid fever, and delirious- 
or unconscious, have been fed with success by this method in my 
wards. 

The method of procedure is similar to that used in stomach wash- 
ing. It is best not to introduce the catheter through the nose, but 
to keep the mouth open with some device. If the catheter is passed 
through the nose, no food should be introduced into the funnel until 
we are sure the feeding-tube is in the stomach. With older children 
a tube passed through the nose may pass into the larynx. If it 
has done so, a hissing sound will be heard. Aphonia will also be 
present. In infants and young children the glottis is small, and a 
full-sized catheter will not readily pass into it. After the tube is 
in the stomach the prescribed amount of liquid food is introduced 
and the tube rapidly withdrawn. The feeding may be repeated every 
four to six hours. 

Rectal Enemata; Irrigation; Enteroclysis. 

The bulk of an ordinary enema, introduced in order to empty 
the bowel, should be from 2 to 4 ounces. A Davidson's bulb 
syringe should not be used. A No. 16 or No. 18 catheter is attached 
to the nozzle of an ordinary four-ounce hard-rubber syringe. The 
infant or child is placed on its side, with a rubber sheet under the 
buttock. The tip of the catheter is oiled and passed well within 
the anal ring. The catheter is then attached to the nozzle of the 
syringe containing the fluid to be injected, and the fluid is gently 
thrown into the rectum. An enema commonly used is soap-water,, 
with the addition of a tablespoonful of castor oil or glycerin. 

The high rectal enema, irrigation, or enteroclysis, is given in 
all forms of summer diarrhoea, dysentery, and in typhoid fever. It 
is also indicated in cases in which there are symptoms of collapse, in 
exhausting diseases, in nephritis, and after operations. It is also 
used to reduce intussusception. In diarrhoea, the object of the high 
rectal enema is twofold — to clear out the feces from the lower 
bowel, and to supply fluid to the depleted circulating blood, thereby 
stimulating the heart. The latter is the main object in practising 
enteroclysis in states of exhaustion and after operations. In sup- 
pression of urine we aim to supply fluid to the kidneys and stimu- 
late the circulation. According to Kemp, the high rectal enema 
is one of our most useful diuretics. 

The solution employed is the Cantani saline solution (sodium 
carbonate, 3.0 ; sodium chloride, 4.0 ; water, 1000). At least a 
quart is injected. The temperature of the solution for simple wash- 
ing of the gut, as in diarrhoea, should be that of the body. In 
nephritis or collapse the temperature should be at least 108° to 
110° F. (42.2° to 43.3° C). 



< 

Oh 




0> 
g 

5 



RECTAL ENEMATA; IRRIGATION; EXTEROCLYSIS. 43 

The instrument employed may be a bag fountain syringe, of a 

quart capacity, to which is attached a small calibre soft-rubber 
rectal tube or a catheter, or the rubber tubing and catheter may be 
attached to a six-ounce glass fuunel. 

The patient is completely undressed and laid on a table on the 
side, with the knees flexed and the buttocks near the edge. A 
rubber sheet placed underneath the buttocks leads into a pail, so that 
the returning water will drain off (Plate II.). The buttocks are 
placed slightly higher than the trunk. The catheter or rectal tube 
is oiled and introduced two or three inches into the rectum, the water 
allowed to flow, and the tube passed higher up. Sometimes there is 
an obstruction to the passage of the tube, and then it is necessary to 
introduce the finger cautiously into the rectum alongside of the tube 
and guide it past the upper sigmoid ring. The tube may thus be 
passed from six to eight inches into the gut. It is seldom necessary 
to introduce it higher, as the water will find its way into the colon. 
About a pint or more of water is then allowed to flow into the gut. 
It is not necessary to compress the anus around the catheter to pre- 
vent escape of the fluid. Some of the fluid may escape alongside 
the catheter. In some forms of exhausting diarrhoea a portion of 
the saline solution should be left in the gut after it has been well 
irrigated, in order to stimulate the heart and supply fluid to the 
circulation. Two irrigations may be necessary in the twenty-four 
hours, rarely more. In typhoid fever one low irrigation is given 
daily. In some subjects, if the irrigations are continued too long, 
hyperamiia of the mucous membrane results. Clinically, this is 
manifested by a continuance or increase of mucus in the washings, and 
also by the occasional presence of blood. In such cases the enemata 
must be suspended. In nephritis complicating scarlet fever, rectal 
irrigation is one of the recognized methods of stimulating the secre- 
tion of the kidney, which result, according to Kemp, begins twenty 
minutes after the fluid is introduced into the gut. With adults the 
Kemp tube is used, but with children, who are difficult to keep 
quiet, continuous irrigation is not feasible. In these cases high 
enteroclysis is given in the ordinary manner, as much of the solu- 
tion as possible being retained in the rectum. This procedure may 
be repeated two or three times daily. In giving ordinary entero- 
clysis the bag of the fountain syringe or funnel should not be held 
more than three feet above the body of the patient, lest the pressure 
be too great. About a pint of fluid at a time is allowed to flow into 
the gut ; the catheter is then disconnected, and the contents of the 
gut allowed to flow out. 

A stimulating enema is given after an operation, or when symp- 
toms of collapse appear in any acute illness. Only small quantities 
of solution are allowed to flow into the rectum. A formula in use 
in my wards is the following : 



44 INFANCY AND CHILDHOOD. 

Whiskey gj. 

Caffeine gr. J. 

Tinct. digital gtt. ij. 

Sol. sodium chloride (0.6 per cent.) ^j. 

Temperature, 102°-105° F. 

Nutritive enemata are used when for any reason, such as uncon- 
trollable vomiting, the stomach must be given complete rest. Sorna- 
tose solution, §j at a time, is given every four hours. Or, ext. 
pancreatis, gr. v; sod. bicarb., gr. ij ; water, ^iv ; milk, ,?xvj ; with 
or without the addition of an egg. Give ^j or ^ij. These enemata 
should be given slowly and high up, and in small quantities at a time. 

For constipation the following is excellent : 

Olive oil ^ij. 

Glycerin s;j. 



HYGIENE OF INFANCY AND CHILDHOOD. 

The First Bath. — The temperature of the room in which the 
newborn infant is bathed should be from 70° to 72° F. The bath 
should be given near an open fire or a stove, in order that the infant 
may not be chilled. To remove the vernix caseosa, the body is 
anointed with olive oil, vaseline, or benzoinated lard ; of these, 
vaseline is more irritating than olive oil. In anointing the body, 
only a portion of the surface is exposed at a time. The object of the 
bath is to remove bacteria or substances which may decompose on 
the surface of the body. The washing should be done rapidly and 
thoroughly. The temperature of the water used should be 100° F., 
and not 96° F., as recommended by some. The baby is taken from 
the bath, placed in a dry, warmed towel, and carefully dried. The 
skin must not be rubbed too harshly or unduly stretched, especially 
in the groin and axillae. If roughly handled, the skin in these 
regions will crack and fissures will be produced. 

The cord is dressed with absorbent, sterilized gauze. The gauze 
is folded four times into a pad three by four inches, and a hole for 
the passage of the stump of the cord is cut through the centre. The 
gauze is then folded over the stump, the whole laid flat against 
the abdomen, and the binder applied. This dressing is changed 
daily. 

The Eyes. — Immediately after the first bath a drop of a 2 per 
cent, solution of silver nitrate is dropped into each eye. This is a 
prophylactic measure against gonorrhoeal ophthalmia. The eyes are 
washed once daily with lukewarm water to which a pinch of salt has 
been added. 

The Daily Bath. — The infant should be bathed daily in the 
forenoon, one hour after nursing. The temperature of the water 



HYGIENE OF INFANCY AND CHILDHOOD. 45 

may vary from 96° to 98° F. during the early months; after the 
sixth month the temperature may be as low as 90° to 92° F. Cold 
baths and cold sponging are not beneficial for infants. The first 
bath reduces the temperature, so that the normal status is not 
regained for a period of from one to three days. During early 
infancy the temperature of the bath should not be lowered. Reduc- 
tion of the temperature of the bath or of the room distinctly retards 
increase in weight. Moreover, we should not attempt in this way 
to " harden " the baby. Some infants may be unduly chilled during 
any bath. For this reason the precautions mentioned in the section 
on the Newborn Baby's Bath must be observed. 

The temperature of the room in which an infant sleeps should 
be at least 70° F. The room should be well ventilated and free from 
draughts. An open fireplace with a log fire is the most hygienic 
method of ventilating; a nursery. As stated above, the infant must 
be protected from wide variations of temperature, in order that its 
vitality may not be reduced, and the increase of body-weight may 
progress in a physiological manner. 

The Body Binder. — The binder should be of soft, thin, 
white Shaker flannel, five inches wide and sufficiently long to pass 
two or three times round the body. It is secured with strings, not 
with pins. It is useful at first in retaining the dressing of the cord 
in place, and later on in supporting the umbilicus during straining 
and attacks of crying. The binder is discarded when the infant 
first attempts to stand — usually at about the seventh month. 

Clothing". — The clothing of the infant should consist of a 
chemise of wool next the skin, and over this should be a loose gar- 
ment, also of wool or flannel, reaching from the shoulders to below 
the feet, and sufficiently long to allow of being folded upward. Gar- 
ments should not constrict the chest. The chemise, which should 
be of gauze weight in summer, is worn both winter and summer. 
In some infants contact of w T ool with the skin causes an eruption of 
sudamina. This may be avoided by placing a fine linen chemise 
next the skin, and over this the gauze wool garment. 

The Skin. — The precautions to be observed in drying the skin 
have already been mentioned. Dusting powder is best applied with 
a puff of absorbent cotton. This can be thrown away and a new one 
used at each dressing. In order to prevent caking, any excess of 
dusting powder should be removed. 

If the skin is subject to sudamina in the summer, the bath should 
contain bran. A handful is added to the water, or the bran is put 
into a gauze bag and this is placed in the water ; when w T ell soaked 
the bran is expressed into the bath. Salt water irritates a skin 
which is the seat of sudamina. 

The Mouth. — It was formerly customary to wash the mouth of 
the infant thoroughly twice or thrice daily. This is no longer done. 



46 INFANCY AND CHILDHOOD. 

The month of the breast-fed infant should not be washed. If the 
breast nipple is kept scrupulously clean, sprue or stomatitis will be 
avoided. The nipple of the nurse's or mother's breast should be 
cleansed with a solution of boric acid before and after each nursing. 
Before the eruption of the teeth the natural secretions of the mouth 
are quite sufficient to keep, the mouth clean. After the teeth 
appear, they are kept clean by washing them gently twice a day with 
a piece of lint wet with boric acid solution. With bottle-fed infants 
the procedure is somewhat different. The mouth is cleansed once a 
day by means of a piece of lint and warm water or solution of 
boric acid. The utmost gentleness should be used. The roof of 
the mouth and the hamular processes of the palate bones are avoided, 
since friction in these localities will invariably cause ulceration 
(Bednar's aphtha?). The fingers and the nails should be carefully 
cleansed before introducing them into the mouth. The bottle 
nipples should be boiled in water once a day for fifteen or twenty 
minutes, and cleansed with hot water after each nursing. In the 
intervals of nursing the nipple is kept wrapped in a piece of clean 
absorbent gauze. In this way sprue will be avoided. 

The Diaper. — After each movement the infant is gently cleansed 
with a piece of lint or old washed muslin and water. A sponge 
should not be used. The parts are dusted and the excess of powder 
blown away. The bulk of the feces is removed from the diapers, 
which are then allowed to soak either in a weak solution of carbolic 
acid (1 : 1000) or in sublimate solution before being placed in the wash. 
After changing the diapers the nurse's hands and nails should be 
scrupulously cleansed with brush and file. This cleanliness of the 
hands is important even with breast-fed infants, since in this way 
contamination of the infant's food with fecal bacteria is avoided. 
Diapers are boiled in water to which soda has been added. A clean 
diaper should be aired and warmed before being applied to the infant. 

Temperature. — The temperature of infants is always taken in 
the rectum ; that of older children is also taken in the rectum when 
possible. In some children there is an innate modesty which for- 
bids the use of the rectum for this purpose ; in these subjects the 
temperature should be taken in the mouth or axilla. All patients 
should have thermometers of their own. 

In the newborn infant the temperature will vary from 36.9° to 
38.4° C. (98.4° to 101.1° F.) ; the latter is exceptional. Accord- 
ing to the studies of Lachs, the average temperature of the new- 
born infant varies from 37.5° to 37.9° C. (99.5° to 100.2° F.). 

After the first bath the temperature falls from one and a half to 
two and one-tenth degrees F. Two hours after the bath the tem- 
perature begins to rise, and reaches its original height within twenty- 
four hours, sometimes later. In premature and weakly infants the 
temperature does not reach the original figure for fully three days, 



HYGIEXE OF INFANCY AND CHILDHOOD. 



47 



and in some infants it may never reaek the original height. The 
body temperature of infants shows slight fluctuations during the 
day. The maximum temperature is in most cases reached at mid- 
day and afternoon ; the minimum during the morning and evening. 
The daily fluctuations vary from one-tenth to three-tenths of a 
degree F. During sleep the temperature sinks from three-tenths to 
one-half a degree F. (Alix, Vierordt). In general, we may say 
that in infants and children any temperature from 99.3° to 100° F. 
in the rectum is normal. 

The following table of body temperatures is compiled from 
Lachs, Vierordt, Alix (rectal) : 

Newborn infant 37.5° to 37.9° C. : 99.5° to 100.2° F. 

5-16 months 37.4° to 37.9° C. : 99.3° to 100.2° F. 



20 months-4 years 



37.5° to 37.9° C. ; 99.5° to 100.2° F. 



5-9 years 37.6° to 37.8° C. ; 99.6° to 100.1° F. 

The Breasts of the Newborn Infant. — From the third to the 
fifth day after birth milk appears in the breasts of both sexes. As 

Fig. 10. 




Caking of the milk in both breasts of a newborn infant. 

•a rule, the secretion appears earlier in girls. The breasts may 
become swollen and tense. Sometimes one gland, generally the 
right, functionates sooner than the other. The secretion has been 






48 INFANCY AND CHILDHOOD. 

examined by Barfurth, Herz, and others, and found to be composed 
of proteids, 2.5 to 3.6 per cent. ; fat, 2.5 to 3 per cent. ; and sugar, 
2.5 per cent. It is a secretion of milk. The method of secretion 
is the same as in the adult gland. The amount of milk, which is 
called by the laity " Hexen milch " (Ger.) or witches' milk, is small. 
The breasts should be kept scrupulously clean. If they become tense, 
they should not be rubbed or manipulated. We cannot bandage these 
breasts, as in the adult, for the thorax being resilient, the bandage 
may interfere with the respiratory movements and thus cause 
serious pulmonary trouble. The secretion of milk lasts, as a rule, 
from six to eight weeks ; in exceptional cases it may continue six 
months (Herz). Mastitis is the result of infection, and not of caking 
of the breasts. If actual caking occurs, it is permissible to massage 
the breast gently once a day with sterilized oil. The index finger 
is moistened with a drop of the oil and the gland is gently stroked 
in a circular direction for five minutes. Before performing this office 
the breasts and the finger should be scrupulously cleaned to avoid 
infection. Cold applications or applications of ointments are to be 
avoided. If the breasts are soft, even though tense, they should be 
let alone. 

Open Air. — An infant may be taken into the open air two weeks 
after birth in summer, and three weeks after birth in winter. After 
this a daily open-air ex-posure is allowable in good weather. If the 
infant is warmly clad in winter, there is no danger. A veil should 
be worn in order to protect the skin of the face from the irritation 
of dust. A delicate skin thus protected will not become eczematous. 
Two hours in the open air in the forenoon and two in the afternoon 
are sufficient. The infant should be indoors after 4 p. M. 

Sight. — According to Preyer, the infant during the first month 
will awaken if a bright light is suddenly flashed in its face. At the 
seventh month it distinguishes objects apart. 

Hearing. — A baby does not hear in the true sense of the word 
until the beginning of the second month. After this, hearing de- 
velops, and loud talking and noise will disturb it. At the ninth 
month the infant attempts to articulate and talk. 

Standing and Walking. — The infant will try to stand in the 
arms of the nurse or mother at the seventh month. At the tenth 
month it will stand without aid. At the eleventh month it will 
attempt to walk if aided. At the sixteenth month it will walk 
without aid. The infant should not be allowed to sit up until the 
seventh month, at which time its attempts to stand are evident. 

NATURAL FEEDING OF INFANTS AND CHILDREN. 

Although many infants can be successfully reared with our im- 
proved methods of substitute feeding, the breast-fed infant is in the end 



PLATE III. 

FIG. 1. 




Form of the Breasts of a Wet-nurse with Abundant 

Milk Of Good Quality. (After Sehliehter.) 
FIG. 2. 




Form of the Breasts of a Wet-nurse whose Milk is 
Deficient in Quantity and Quality. (After Sehiiehter.) 



SELECTION OF A WET-NURSE. 49 

better fitted to enter upon the struggle for existence than one fed on 
the bottle. Xo matter how skilfully artificial food may be prepared, 
it will not in some cases be assimilated. Great difficulty is experi- 
enced in feeding premature infants with the bottle. Some infants, 
when deprived of the breast, suffer from colic and have green curdled 
movements, are restless, and cry all night ; others have a moderate 
amount of colic, and the movements are yellow and contain whitish 
curds. Such infants lose ground steadily, or remain stationary in 
weight. They should not be kept on the bottle ; they will not 
thrive no matter how we may modify the milk. There are other 
considerations which make it desirable that the infant should, if 
possible, take the breast. Even if the milk is insufficient in quan- 
tity, it is a mistake to reject it wholly. In such cases the baby 
should be fed on the breast, aided by the bottle. Finally, in spite 
of the disadvantages of placing a baby at the breast of a stranger, 
both from a moral and an economic standpoint, we should endeavor 
to feed every infant on breast milk. Failing in this, we must have 
resort to a substitute. 



Selection of a Wet-nurse. 

It is not necessary that the wet-nurse should have been recently 
delivered. A newly born baby may be given the breast of a nurse 
whose baby is from one to two months of age. In fact, her milk is 
preferable to that of a nurse who has just been confined. For, 
apart from the uncertainty as to whether the milk will agree with 
the baby, the milk after a few weeks attains a uniform constitution, 
and is more likely to agree with the baby than milk from the breast 
of a woman recently confined. I prefer to place the newly born 
infant on a breast at least three weeks old. 

The method of examining a wet-nurse as to her fitness begins 
with ascertaining the history of her own baby. It should sleep 
well in the intervals of nursing, be free from colic, and have normal 
movements. The baby should be completely undressed for exami- 
nation. It should be at least tolerably well nourished. Xo eruption 
should be visible on its skin. There should be no copper-colored 
intertrigo, no snuffles, no pigmented spots, and no rhagades around 
the mouth or anus. The head should not have an idiotic, microce- 
phalic conformity. The wet-nurse should be below the age of thirty. 
Old multipara do not, as a rule, furnish good milk. The shape of 
the breast is important. The pear-shaped, elongated, hanging breast 
furnishes more milk than the firm round breast of virgin shape 
(Plate III.). The nipple should be about one centimetre long and 
three-fourths of a centimetre in diameter. The baby can easily 
grasp such a nipple and draw it into the mouth. A flat nipple, or 
a nipple with fissures, or a nipple surrounded by eczema, is not desir- 



50 INFANCY AND CHILDHOOD. 

able in a nurse, and may even be dangerous to an infant. The 
nurse is next directed to undress, and her body is examined for 
traces of any eruption which may be specific. Pigmented macules 
should arouse suspicion. The lungs, especially the apices, are 
examined for bronchitis or tuberculosis. The nurse is rejected if 
there be the slightest evidence of apical involvement. The teeth 
should not be carious to such an extent as to preclude their being 
kept clean. The presence of a fetid ozsena is highly objectionable, 
apart from the offensive odor. Such cases may be latently tuber- 
culous. The woman should be mentally sound. The wet-nurse is 
then examined as to the presence of venereal disease by inspection 
of the introitus vaginae and the anus. Search is made for mucous 
patches and suspicious cicatrices. After having examined both child 
and mother in the manner detailed, we are in a position to recom- 
mend the nurse if the milk is satisfactory. 

The physician should have at hand in his office means by which 
he can at once decide upon the desirability of a wet-nurse. He must 
not at the beginning be driven to the necessity of a milk analysis. 
He decides first as to the quantity and then as to the quality of the 
milk. As a rule, a wet-nurse comes to the physician insufficiently 
fed and in a frame of mind far from tranquil. If despite these 
conditions the milk possess the qualities desired, he may at once 
venture to place the baby at the breast. If the milk does not agree 
with the baby after a fair trial, future conduct will be guided by 
certain developments, both in the quantity and quality of the milk 
and the condition of the infant. 

Quantity of the Milk. — The physician grasps the breast in the 
palm of his right hand and gently but firmly attempts to express 
the milk. The milk should with gentle pressure flow freely from the 
ducts. A drop is caught on the nail of the thumb. This time- 
honored nail-test is not to be despised. A drop of good milk 
will retain its bluish-white tint. This test will bring out the color 
of the milk, whether too watery, yellow, or white, to the experienced 
eve. The nurse is then directed to pump by gentle pressure a 
quantity of milk into a long, narrow beaker glass. If the breast 
has not been nursed within an hour, there should be no difficulty in 
obtaining at least an ounce of milk in this way. With this quan- 
tity we can at once decide on the efficiency of a nurse. The milk 
should have a bluish-white tinge. Any trace of yellow or green 
when a test-tube of the milk is held in the light, is abnormal. 
Milk may be very abundant but of a dirty white tinge ; some 
specimens separate almost instantly upon withdrawal into a yel- 
lowish oily layer on top and a serous liquid below. Any such ab- 
normalities in the milk should cause the rejection of an applicant. 
If the breasts, history, and physical examination are satisfactory, 
and the quantity and physical characteristics of a nurse's milk are 



PLACING THE BABY AT THE BREAST. 51 

good, we may recommend her without making a chemical examina- 
tion of the milk. Such an examination is impracticable for the 
practitioner with the means at his disposal. Even if carried out, it 
may be unfair to the nurse. At the examining visit the proportion of 
proteids and fats may be below what it will adjust itself to in a day 
or two when the wet-nurse is rested and housed in her new home. 
More nutritious diet will greatly change the composition of the milk. 
There are, however, conditions which may require an examination 
of the milk at a subsequent period. In such a case the methods 
to be hereafter detailed may be resorted to. 

The Mother has Milk, but it is Insufficient in Quantity ! 

It often happens that a mother has a small supply of milk in 
one or both breasts. The question arises : Should we reject such a 
breast and seek a nurse with an abundance of milk, or place the 
baby wholly on the bottle ? I very strongly advise all such mothers 
to feed the baby partly at the breast and partly on the bottle. This 
is good morally in that it gives the mother the satisfaction of 
nursing her offspring. Furthermore, infants thrive better on mixed 
feeding of the breast and bottle than on the bottle alone. The breast 
milk seems to aid in the assimilation of the cows' milk. I follow 
this plan even if there are only two good nursings a day in one or 
both breasts of the mother. Again, it is common experience that 
suckling a breast in Avhich secretion is at first deficient will develop 
and stimulate the secretion of the breast. 

Contraindications to Nursing the Infant. 

If the mother is tuberculous, demented, or epileptic, the babv 
should not nurse the breast. On the other hand, she may suffer from 
syphilis or skin eruptions, or may have a deficiency of milk, and 
still be allowed to nurse her infant. A wet-nurse, on the contrary, 
must be free from all constitutional taint to be fit to nurse an infant 
other than her own. 

Placing the Baby at the Breast. 

The question is constantly raised : Should the newly born infant 
be placed at the breast during the first twenty-four hours? If, after 
the babe is born, it sleeps and awakens only when the diaper is to 
be changed, and then falls asleep again, it is obviously not necessary 
to place it at the breast. If, however, the infant cries, is uneasy, 
and refuses to be quieted, we may, six hours after delivery, place it 
at the mother's breast. There are then a few drops of colostrum in 
the breast, and the infant will be quieted with this. Should this 



62 INFANCY AND CHILDHOOD. 

not appease the infant, which rarely happens, it may be given a 
tea spoonful of sugar-water every two hours. On the second day 
there will, as a rule, be more milk in the breasts, and on the third 
day the secretion is more active, and may even cause caking of the 
breast. 

Care of the Breast. 

The care of the mother's breast directly after the birth of the 
child is important. If we begin correctly, much trouble will be 
avoided. 

Caking. — The breasts are closely watched to prevent so-called 
caking. If the baby nurses and leaves a residual amount of milk 
in the breast, this milk should be pumped off with an ordinary bulb 
breast-pump. The most satisfactory pump is one with a glass bell 
and a rubber bulb. Pumping the breast at first, when the milk is 
forming, will prevent caking and rapidly regulate the secretion to a 
normal amount. If caking occurs, the breast should be rubbed or 
massage performed three times daily. The hands of the nurse are 
carefully washed, and anointed with some sterilized oil. The breast 
is then grasped in the palms of both hands, one above and the other 
beneath the breast. The breast is gently subjected to firm pressure 
with a vermicular motion. This massage is kept up five or ten 
minutes. 

Sore Nipples. — Ordinarily, if the nipple of the mother or nurse 
is kept dry and clean, it will not fissure. Fissures, however, occur 
even when much care has been taken to prevent them. In that 
case the baby should not nurse the breast directly, but through a 
rubber shield, which protects the nipple. The fissure is painted 
once daily w~ith a 10 per cent, solution of silver nitrate. If there is 
a discharge of pus from the fissures, or if the breast nipple has a 
focus of suppuration which discharges, the breast should not be 
nursed by the baby, as by so doing the infant may contract an 
infectious diarrhoea. 

Nursing the Infant. 

Nursing. — The baby should nurse about twenty minutes and then 
fall asleep at the breast. The nipple is washed, as already stated, with 
a solution of boric acid before and after each nursing. The breast 
nipple is covered in the intervals of nursing with a small piece of 
absorbent gauze folded several times. In this way the nipple does 
not come in contact with the clothing. Any exuding milk is caught 
on the gauze, which is replaced by a clean piece when necessary. 
The infant, when nursing, should lie in the arms of the nurse. The 
nurse grasps her breast just behind the base of the nipple with the 
index and ring fingers. The thumb may be used to exert pressure 
on the breast, thus aiding the flow of milk. In this way the infant 



NURSING THE INFANT. 53 

is prevented from drawing the nipple too far into the mouth. 
Moistening the breast with saliva or a few drops of milk is repre- 
hensible. The infant will furnish all the moisture needed. 

Intervals of Nursing". — Up to the second month an infant 
should be nursed more frequently than at a later period. At this 
time eight nursings in the twentv-four hours are not excessive. 
From the second to the sixth month, seven nursings in the twenty- 
four hours are sufficient, and after the sixth month six nursings are 
sufficient. The nursings should be so arranged that the nurse and 
baby may have a complete rest of five hours between 12 p. M. 
and 5 a. m. The mouth of the infant is not washed (see above). 

Signs of Efficient Nursing. — An infant at the breast whose 
weight increases in the regular ratio, who sleeps between the nurs- 
ings, and whose bowels are normal, is known to be thriving. It 
may here be proper to give the normal weight curve (Fig. 11). 

Increase of Weight. — During the first two or three days following 
birth the infant decreases in weight. Usually this loss is from 150 
to 200 grammes (5 to 6 \ ounces), but it is sometimes greater. The 
passage of meconium and urine, the exhalations from the skin and 
lungs, and the small amount of nourishment taken, account for this 
loss. As the infant begins to nurse, the weight increases until the 
seventh day, when it will have regained its original weight. On the 
tenth day it weighs 100 grammes (3 J ounces) more than at birth 
(Budin). In some cases, if the infant is placed immediately after 
birth on an abundantly secreting breast, it will not lose any or but 
very little weight. 

Camerer gives a very instructive table which explains the loss 
of weight in the first two days after birth. It will be seen that the 
amount of nourishment is not sufficient to make up for the loss in 
weight. 

Nourishment taken, T oco . Change in 

breast milk, in JgSSeB weI * ht ' 

grammes. grammes. grammes. 

(perspiration, 1001 

urine, 50 Y — 160 

meconium, 40 ) 

{perspiration, 80) 

urine, 60 V — 50 

meconium, 40 ! 

{perspiration, 87 V 

urine, 140 \ + 10 

feces, 3 J 

In an investigation by Gundling it was noted that many infants 
ceased to lose after the second day, and an almost equal number on 
the third day. Boys lost more than girls, and the infants of mul- 
tipara? less than those of primipane. The average loss was 241 
grammes. Most infants regained their original weight by the ninth 
dav. 



54 INFANCY AND CHILDHOOD. 

The tables on page 55 show the progressive increase in weight. 

Fig. 11. 



DAYS 




i 


2 


3 


4 


5 


6 


7 


8 / 


9 


10 


11 


1- 
I 
o 

HI 

3,100 
75 
50 
25 

3,000 
75 
50 
25 

2,900 
75 
50 
25 






































































/ 
























/ 
























/ 






















/ 






















f 




1 
















1 
























/ 
























/ 
























/ 
























/ 
























/ 
























/ 
























/ 






















y 






















/ 
























/ 
























/ 
























/ 
























/ 
























/ 






































































/ 










\ 














/ 










\ 














/ 










v 














/ 










V 














/ 










\ 














/ 










\ 














/ 
























f 












\ 










/ 














\ 










/ 














\ 










/ 














\ 










/ 














\ 










/ 














\ 










/ 
























/ 
























/ 






















/ 
























/ 
















1 








/ 
























/ 
























/ 
























/ 
























/ 
























/ 














































/ 
























/ 




















1 




/ 
























J 
























/ 
























/ 
























f 






















/ 
























/ 
























/ 




















. 


/ 






















W 





















































































































Normal curve of -weight during the first ten days of life (Budin.) 

After six months the infant has twice its initial weight, and at the 
end of twelve months weighs almost 20 pounds (9000 grammes). 



NURSING THE INFANT. 



55 



Fig. 12. 



WEEKS 


-|«."> «■■=:="-,»=• = 2 2 2 1 


2 


= j) 


3 i 




o 


9 t 


a 


8 


- 


§1 ? § ? Is S 


8,500 
8,000 
7,500 






















~? 




























\s 




































X ! 




































- ^^^t 


i ; 


































>*' ' 




































y 




































±A^+- 




































4f. 






































































/ 






































































y 






































































/ 






































































/ 










7,000 
6,500 

CO 

111 

2 6,000 

< 

cc 

o 

5,500 
5,000 
4,500 




























/ 






































































/ 




































/ 






































































* 




































/ 






































































/ 




































/ 




































4 






































































/ 




































/ 




































/ 




































/ 


















x : 
















f 




































f 


































/ 


































/ 




























































i 










/ 


























i 










/ 
































/ 


























/ 
























; / 


































































/ 


















/ 


















4,000 
3,500 


/ 






















































/ 


















/ 


















1 1 1 1/ 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 


: . 


































/ 


















/ 














/ 


















/ 








































i 


' 


1 i 1 J i i 1 1 
















i 


1 





















Normal weight curve of an infant during the first year. (Budin.) 
Normal Average Weight of Breast-fed Infants. (Camerer.) 





Grammes. 






Grammes 


Birth 


. . 3450 En 


d of 24th week 
" 28th " 


. 7 1 30 


End of 1st week . . 


. . . 3400 


. . 7570 


" 2d " . . 


. . . 3490 


" 32d 


« 


. . . 7990 


" 4th " . . 


. . . 3890 


" 36th 


" 


. . . 8400 


" 8th " . . 


. . . 46S0 


" 40th 


« 


. . . 8580 


" 12th" . . 


. . . 5410 i 


" 44th 


« 


. . . . 9020 


w 16th" . . 


. . . 6090 


" 48th 


H 


. . . 9300 


" 20th" . . 


. . . 6650 


" 52d 


11 


. . . 9890 



Daily Increase in Weight in Grammes. 

Weeks. Weeks. Weeks. Weeks. Weeks. Weeks. Weeks. Weeks 

1-2 2-4 4-8 8-12 12-16 16-20 20-24 24-28 

3 29 28 26 24 20 17 15 

Weeks. Weeks. Weeks. Weeks. 

28-32 32-36 36-40 40-52 

15 14 7 15 



56 



INFANCY AND CHILDHOOD. 



For completeness, there may be added the measurements of the 
length of the newborn infant, 49 to 50 cm. (Herz). Boys are on 
the average longer than girls. 

Herz gives the following measurements of the head of the new- 
born infant : 

Circumference 39.2 cm. 

Sagittal diameter 11.1 cm. 

Large transverse diameter 9.0 cm. 



Weight from the first to the . fifth year, by Camerer, in kilos 
(kilo = 2.2 pounds) : 





At birth. 


Boys . . 
Girls. . 


. . 3.4 
. . 3.2 



First 


Second 


Third 


Fourth 


Fifth 


year. 


year. 


year. 


year. 


year. 


9.9 


12.8 


14.9 


16.7 


18.0 


9.2 


14.9 


13.2 


15.0 


16.0 



American-born infants and children have the following weights 
and length of body : 

Length. 

Boys. Girls. 

End of first year 19^ inches. 19 inches. 

" second vear . 27 " 26 " 

" third year 33 " 33 " 

Weight. 

Boys. Girls. 

End of first year 20 pounds. 18-19 pounds. 

Second year to fourth year . 28 " 26 

The following tables by MacDonald are taken from studies on 
children above five years of age : 



Average Boys, American Parents. 



Limits of different 










Average 
circum- 


ages. 


Total 
number of 
children. 


Average 
height. 


Average 
sitting 
height, 


Average 
weight. 








From— 


To— 












Yrs. Mos. 


Yrs. Mos. 




Inches. 


Inches. 


Pounds. 


Inches. 


5 7 


6 6 


36 


44.64 


24.85 


45.01 


20.21 


6 7 


7 6 


175 


46.13 


25.19 


48.07 


20.35 


7 7 


8 6 


285 


47.95 


25.94 


51.76 


20.53 


8 7 


9 6 


286 


49.79 


26.55 


56.17 


20 63 


9 7 10 6 


305 


51.63 


27.18 


61.43 


20.75 


10 7 11 6 


320 


53.24 


27.98 


66.40 


20.85 


11 7 12 6 


389 


55.17 


28.74 


73.19 


20.90 


12 7 13 6 


360 


56.71 


29.39 


79.94 


20.96 


13 7 14 6 


311 


58.99 


30.60 


88.48 


21.27 


14 7 I 15 6 


186 


61.82 


31.63 


99.83 


21.40 


15 7 


16 6 


119 


64.11 


33.12 


114.28 


21.64 



NURSING THE INFANT. 



57 





Girls of 


American 


Parentage. 






Limits of different 










Average 
circum- 
ference of 
head. 


ages. 


Total 

number of 
children. 


Average 

height. 


Average 
sitting 
height. 


Average 
weight. 


From— To— 












Yrs. Mos. Yrs. Mos. 




Inches. 


Inches. 


Pounds. 


Inches. 


5 4 6 6 


64 


44.47 


24.36 


48.52 


19.88 


5 5 6 11 


37 


43.97 


28. S7 


42.90 


20.20 


(15 7 6 


375 


45.09 


24.69 


45.74 


19.94 


7 7 8 6 


587 


47.43 


25.49 


49.33 


20.13 


7 9 6 


669 


49.21 


26.19 


58.47 


20.29 


9 7 10 6 


737 


51.22 


27.i Ml 


58.53 


2(U5 


10 7 11 6 


721 


53.15 


27.81 


63.98 


20.55 


11 7 12 6 


673 


55.81 


29.06 


72.83 


20.78 


12 7 13 6 


706 


58.05 


80.21 


82.42 


20.97 


18 7 14 fi 


627 


60.25 


31.43 


92 96 


21.18 


14 7 15 6 


490 


61.64 


32.28 


100 69 


21.29 



Movements of the Bowel. — An infant's stool is normal if it is 
yellow in color, of the consistency of thick paste, and does not con- 
tain white flakes. The pasty, unformed stool is characteristic of the 
infant. If the feces are passed in round masses, the movement is 
abnormal. If a dejection presents white or greenish masses, con- 
tains mucus to an appreciable degree, is green when passed, or is 
partly pasty and partly fluid, it is abnormal. Any movement may 
turn green after exposure to the air for any length of time. 

The number of movements passed daily varies. Some infants 
have regularly one normal movement daily ; others, two or more. 
The author has met infants in good health who had at times six 
normal movements daily. Henoch has called attention to this fact. 

Signs of Insufficient Breast-feeding. — A baby is not thriving 
on the breast if its weight remains stationary for even a short time. 
For this reason babies should be weighed at least twice a month. 
At the first discovery of stationary weight an infant should be 
weighed every three days, in order to see if it increases in weight. 
If the weight continues stationary, the milk should be examined. 
It may be deficient in quantity to such an extent as to no longer 
fully satisfy the baby. In that case the infant will be observed 
to nurse the breast for a long time ; or it may nurse the breast a 
short time and then relinquish it and begin to cry; or it may 
cry in the intervals of nursing. All these are signs of insufficient 
food. In such cases, the breast is examined just before a regular 
nursing, in order to estimate the quantity of milk in the breast. 
The breast is also examined after nursing. In this way the physi- 
cian can determine whether the quantity of milk secreted is sufficient. 
The movements of insufficiently fed infants are dry and constipated. 
The author has seen the character of the stools improve upon 
increasing the quantity of food, either from the breast or by sup- 
plementing the breast with the bottle. In some cases the baby 
cries and has colic, the movements are passed with a good deal of 



i 



58 INFANCY AND CHILDHOOD. 

flatus and are irregular in consistency and color. Here the quan- 
tity of the milk may be sufficient, but its quality is not up to the 
required standard. The nurse's milk should be examined — excite- 
ment may have caused a change in it. Under the heading of Milk 
and Its Analysis, it will be shown that regimen and exercise can do 
much to remedy deficient milk. 

Composition of Human Milk. 

Human milk is so variable in composition that definite knowledge 
on many aspects of its chemistry is still lacking. The older analyses 
of human breast milk give the gross amount of proteids. Hoppe- 
Seyler suggested that the casein should be determined apart from the 
total proteids. Analyses which deal with total proteids are not so 
useful to the physician as those which deal with the casein apart 
from the proteids. The importance of this point will become 
apparent on comparing the milk of the human being with that 
of the cow. 

Konig's analysis, as modified by White and Lladd, gives the 
following composition of human milk and cows' milk : 

Cow. Human. 

Caseinogen 2.88 0.59 

Whey proteids 053 L25 

3.41 1.84 

The casein in cows' milk comprises five-sixths of the proteids ; 
in human milk, two-sixths of the total amount. We should bear 
this important fact in mind in reading the following tables compiled 
from Camerer and Soldner, showing the composition of human milk : 

Ether ext. 
fat. 

Colostrum 5.0 

Milk, fifth day 2.3 

Milk, ninth day 3.4 

Milk, first month 2.6 

Second and third months 2.4 to 1.8 

Backhaus gives the following table of average composition (in 
100 parts) of human milk : 

Water 88.20 

Proteids / °' 75 casein - 

"I 1 .00 albumin (whey proteids). 

Fat 3.50 

Sugar 6.20 

Ash 0.25 

On comparing these figures with those of Konig, White, and 
Liadd, it will be seen that White and Lladd include all the proteids 



Milk- 


. 


sugar. 


ro ei 


4.5 


3.5 


6.7 


1.6 


6.7 


1.4 


7.3 


1.1 


7.5 


0.9 



COMPOSITION OF HUMAN MILK. 59 

exclusive of casein under the name of whey proteids. The whey 
proteids are principally lactalbumin and lactoglobulin. 

Human milk is a bluish-white fluid, amphoteric in reaction. 
It is relatively more alkaline but absolutely less so than cows' 
milk. The specific gravity ranges from 1028 to 1034. It is lower 
in poorly nourished women. The essential difference between human 
and cows' milk lies in the casein. Human milk is not only poorer 
in casein than cows' milk, but the casein is less in proportionate 
combination with the remaining proteids, lactalbumin, etc., than in 
cows' milk. This in part explains the more flocculent nature of the 
casein coagulum in human milk apart from its alkalinity, which 
must also have an influence on coagulation, as noted in the chapter 
on Stomach Digestion. Human milk contains, in addition to lecithin 
and nucleon, more combined phosphorus than cows' milk in the 
nu el eon (Siegfried). 

The casein of human milk is derived from the protoplasm of the 
cells of the mammary gland. Fat is set free from the cells of the 
gland in which fat is formed. Iodine, arsenic, antimony, zinc, lead, 
mercury, and iron pass from the blood into the milk of the human 
breast. Iodine has caused iodism in the nursing infant when taken 
by the nurse in the form of the iodides (Koplik). 

These facts are of practical interest to the physician. Very 
important is the fact that not only does the total of proteids and fats 
in the milk of various women vary to the extent of 1 per cent, or 
more, but also the milk of the nursing woman varies at different hours 
of the day, as may be seen in the following table by Schlichter : 

Nurse A. Casein. Fat. Proteids. Sugar. 

Morning 1.10 0.80 1.69 7.11 

Xoon 1.10 1.88 2.16 6.92 

Night 3.16 1.95 6.83 

Nurse B. 

Morning 0.55 3.77 1.19 5.37 

Noon 0.77 3.90 1.91 6.15 

Night 0.71 3.73 1.26 6.19 

Nurse C. 

Morning 0.55 3.61 0.19 6.18 

Noon 0.83 4.21 1.08 6.21 

Night 0.41 3.60 1.16 6.17 

Can the Composition of Woman's Milk be Altered at Will ? — 
I think that this question is still sub judice. Although it is possible 
to improve the nurse's milk by increasing the general nutritive quali- 
ties of her diet, we cannot always cause increase or diminution in 
the casein or fat by giving certain articles of food. If a nurse has 
been on an insufficient diet, it should be increased in a general way. 
She should have a moderate allowance of meat, partake sparingly 
of tea, coffee, and beer, and have sufficient exercise. If the milk 
does not improve, the nurse should be replaced by another. If the 



60 INFANCY AND CHILDHOOD. 

infant has been suckled by its mother, the deficiency if only one of 
quantity should be supplied by mixed feeding. 

Influence of Foods on the Breast Milk. — A diet rich in nitro- 
genous substances increases the quantity of the milk and the per- 
centage of fats and proteids. A diet rich in fats may increase the 
fat of the milk. On the other hand, it is not always possible to 
increase by means of the diet the casein in milk poor in this con- 
stituent (Konig). Starvation lessens the quantity of the milk and 
the proportion of the casein to the other proteids, as does also a poor 
dietary (Decaisne). Enriching the diet improves the milk. Beer 
and malt liquors increase the quantity of milk and its fat constituents 
(Konig). In this connection, we should not lose sight of the fact 
that the milk of a good breast may be made unfit for the infant by 
placing the nurse on a diet to which she is unaccustomed. Women 
accustomed to a wholesome, moderate dietary will, if fed liberally 
with fats and carbohydrates, secrete a milk rich in fat and poor in 
proteids. This Avill at once disagree with the infant (Konig). 

Menstruation has no appreciable effect on the milk. Pregnancy 
does not always change the milk perceptibly in the first months. This 
has been my experience, and it corresponds with that of Budin. Monti 
asserts that with the advent of pregnancy the milk changes into a 
colostrum. The milk of a pregnant woman should be discontinued 
after the third month. Up to that time it is well to examine the 
milk and the baby in order to determine the fitness of the milk for 
the baby, and also its continued well-being on such milk. 

The presence of drugs and aromatics in the milk has been men- 
tioned. The author has seen the milk of women who had eaten 
asparagus disagree with infants. Excessive purging with pills con- 
taining aloes and belladonna may have a similar effect. 

Bacteria in Breast Milk. 

It is now known that bacteria exist in the breast milk of 
women in good health. The bacteria belong principally to the 
Staphylococcus albus class. Staphylococcus pyogenes aureus and 
some few streptococci have been found (Cohn and Neuman). On 
the other hand, staphylococci and streptococci are quite fre- 
quently found in the milk of women whose breasts are suppurating 
or are affected with rhagades and fissures. Escherich found bacteria 
in the breast milk of women suffering from puerperal sepsis. Pneu- 
mococci have been found in the milk of women suffering from 
pneumonia (Foa, Bordoni-Uffreduzzi). 

Methods of Analysis of Human Milk. 

In the section treating of the examination of the milk of the nurse 
or mother it was shown that with experience it is possible to decide 



METHODS OF ANALYSIS OF HUMAN MILK. 



61 




Aef] 



Fig. 14. 



W ■ 4 



1205 



in a general way as to the quality 
of the milk without chemical anal- 
ysis. Emergencies, however, arise 
which may necessitate more care- 
ful examination of the milk in 
order to clear up some disturbing 
symptom in the infant. After 
thriving for a few weeks the in- 
fant may, without apparent cause, 
cease to gain in weight, or the 
movements may be abnormal, or 
there may be colic. Under these 
conditions it is certainly an advan- 
tage to be able to determine the 
composition of the milk, since a 
chemist is not always at hand. 
Conrad, a physician in Berne, has 
devised some instruments which 
are easily manipulated and are 
within the reach of every physi- 
cian. His article, published in 
1880, is still unsurpassed in 
clearness of detail. The milk 
to be used in all analyses is that 
obtained in the mid-period of 
nursing. 

Specific Gravity. — To ascer- 
tain the specific gravity, Conrad 
reduced the size of Quevenne's 
lactodensimeter so that it could 
be utilized for taking the specific 
gravity of small quantities of 
mother's milk (Fig. 14). The 
specific gravity is taken at 15° C. 
The scale runs from 1020 to 
1050. 

Fat. — Conrad estimated the 
fat by first calculating the cream 
layer. This he determined by 
means of a graduated glass cylin- 
der devised by Bouchardat, Q.ne- 
venne, and Chevalier. This cylin- 
der he reduced in size. The 
method is so unreliable that it is 
merelv mentioned in passing. 

Of greater reliability is the Conrad ^ e \ a e c ; obutyr - Conm Z&T 6en ' 



62 



INFANCY AND CHILDHOOD. 



Fig. 15. Marchand tube, reduced in size by Conrad. The set consists 
of two of these tubes. Each tube analyzes 5 c.c. of milk 
(Fig. 13). 

Five c.c. of milk are poured into the tube, and then 5 c.c. 
of ether. These are well shaken after a drop of officinal 
caustic soda solution has been added. Absolute alcohol 

is then added up to the 



Fjg. 16. 



Fig. 17. 



— y 2 



Instruments employed in the estimation of fat in 
milk. Lewi's method. 



A mark. The whole is 
again shaken and placed in 
water at 35° to 40° C. for 
ten or fifteen minutes. The 
fat separates above, and is 
read off. A percentage table 
accompanies the instrument. 
This instrument is not accu- 
rate. There is a variation 
of from 0.2 to 0.5 per cent, 
or more. Two analyses are 
made at the same time for 
the sake of accuracy ; hence 
the two tubes. 

Lewi's Method. — More ac- 
curate than Conrad's is the 
method worked out in my 
clinic by Lewi. This is really 
an adaptation to mother's 
milk of the Babcock sul- 
phuric acid method, as modi- 
fied by Leffman and Beam. 

The apparatus needed 
comprises a reduced Babcock 
bottle, a pipette for measur- 
ing the milk and acid, and a 
smaller 1 c.c. pipette accu- 
rately divided into cubic 
millimetres (see Figs. 15, 16, 
and 17). 

Method. — Fill the pi- 
pette to the meniscus (this 
represents 2.92 c.c. of moth- 
er's milk), and introduce this 
carefully into the body of the 
bottle, so that the long, thin 
pipette comes down into the 
body of the bottle. The 
pipette is cleansed, and re- 



METHODS OF ANALYSIS OF HUMAN MILK. 



63 



filled to the meniscus with chemically pure sulphuric acid ; the 
pipette is introduced as before. This precaution is taken in insert- 
ing the pipette so that at this stage no ebullition shall occur in the 
neck of the bottle, and so invalidate the result. Next, fill the 
1 c.c. pipette up to the sixth marking with a mixture of equal parts 
of fusil oil and concentrated hydrochloric acid ; add this to the milk 
and sulphuric acid, and fill the bottle with equal parts of sulphuric 
acid and water. The bottle is placed in an aluminum receiver and 
adjusted to the centrifuge. The specimens are revolved one and a 
half to two minutes, and the reading is then taken. With the new 
high-gear machine of Richards & Co. fifteen revolutions of the 
handle per minute suffice, each turn of the handle corresponding 
to one hundred and thirty revolutions of the bottle. 

This method, if carefully carried out, gives very little error, and 
is practically equal to the Soxhlet quantitative fat estimation. It 
can be applied to cows' as well as to human milk. 

The following table shows the error in the various methods as 
compared with accurate chemical determination : 



Soxhlet 
(chemical). 


Reduced 
centrifuge. 


Marchand. 


Feser. 


Specimen I. . . . 


. 4.4 per cent. 


4.4 per cent. 


3.48 per cent. 


5.00 per cent. 


II. . . 


. 1 2.4 


2.3 


2.56 


2.37 " 


III. . 


. 1 1.1 


1.1 


1.44 


1.25 


IV. . 


. 3.9 


3.8 


3.17 


3.25 


VI. . 


. 4.6 


4.7 


2.35 


3.80 


VII. . 


. 2.3 


2.3 


3.99 


2.20 " 


VII. . 


. 4.4 


4.2 


3.68 


4.20 " 


VIII. 


. i 4.7 


4.6 




3.60 



The Proteids. — To possess clinical value in the determination 
of the proteids, a method must differentiate between the amount of 
casein and that of the other proteids, such as lactalbumin and lacto- 
globulin. This is possible only by careful and exhaustive quanti- 



Fig. 18. 




Milk burette of Woodward. 



tative chemical analyses. The methods at our disposal which are 
practicable in the physician's office determine only the gross proteids. 
The gross proteids may be normal in amount, and the casein or 



04 INFANCY AND CHILDHOOD. 

caseinogen be deficient. Such milk would not be nutritious. This 

was demonstrated years ago in sick and starving women (Decaisne). 

The following is the method of AVoodward for determining the 

total proteids : Two "milk burettes" (Fig. 18), each containing 

5 c.c. of milk, are allowed to stand overnight in a warm place 
(100° F., 38° C). They are then cooled. The milk is drawn off 
into two Esbach's tubes, and 10 c.c. of the Esbach solution added. 
The tubes are then shaken, put into a centrifuge, and rotated until 
the reading is constant. This method was perfected in the Pepper 
Laboratory, Philadelphia. The author has applied it in a few 
cases, and found it satisfactory. 

Microscopical Examination of Human Milk. 

On placing a drop of human milk under the microscope, highly 
refracting spherical bodies are seen. They vary from 0.0024 fi to 
0.0046 f± in diameter (Wall) (Plate IV.).' Up to the eighth day 
after the birth of the child the breast milk may, in addition, 
contain the so-called colostrum corpuscles. These are spherical 
bodies four or five times larger than milk bodies. They contain 
granular masses of fat, They are formed in the later months of 
pregnancy and disappear in the course of a week or two after birth. 
Colostrum corpuscles may appear in the milk at any time during 
the nursing period, and are then a sign of intercurrent pregnancy 
or disease. If abundant, they make .the milk unfit for infant con- 
sumption. 



ARTIFICIAL FEEDING OF INFANTS. 

An attempt has been made, especially in France, to rear infants 
on ass's milk, which has a composition identical with that of 
woman's milk. The experiment has, however, failed. To-day cows' 
milk is universally utilized in substitute feeding. Before cows' 
milk can be made suitable for this purpose it must be modified — 
that is to say, the relative proportions of the casein, fat, and water 
must be changed. 

Composition of Cows' Milk. 

Konig gives the following as the average composition of cows' 
milk per 100 parts: water, 87.1; casein, 3.02; albumin, 0.53 ; 
fat, 3.69; sugar, 4.88. Cows' milk has a specific gravity of 
from 1028 to 1034. It is amphoteric in reaction, but is relatively 
more acid than human milk. Fresh cows' milk does not coagulate 
on boiling, but heat causes a skim of casein and lime salts to appear 



PLATE IV. 



1. 





4. 




Microscopical Appearances of Woman's Milk. (After Fleisehman.) 



1. Normal milk, showing the preponderance of medium-sized fat-globules. 

2. Colostrum of later pregnancy. 

3. Poor milk. Preponderance of large fat-globules and a paucity of fat. 

4. Poor milk, a paucity of fat and an almost granular state of the fat-globules. 



ARTIFICIAL FEEDING OF INFANTS. 65 

on the surface of the milk. On standing, lactic acid is formed as a 
result of bacterial growth, and coagulation or curdling of the milk 
occurs when it is heated. After a time an excess of acid causes a 
spontaneous separation of the casein. 

Fat is contained in the milk in the form of fat-globules, which 
arc held in suspension in the serous part of the milk by a zone of 
albumin. There is no doubt that the milk-globules contain all the 
fat of the milk. It is uncertain, however, whether the fat-globules 
contain any protein substances. 

Casein. — The casein of cows' milk belongs to the nucleo- 
albumins. It contains phosphorus, and coagulates when heated, and 
also with the aid of rennet. 

The amount of casein in cows' milk is not only relatively but 
absolutely greater than in woman's milk. In describing woman's 
milk it was stated that in cows' milk the casein forms live-sixths of 
the total proteids in the milk, whereas in woman's milk the casein 
forms two-sixths of the total proteids. This fact is of far-reaching 
importance. Simple dilution of cows' milk leaves it with a 
greater proportion of casein relatively to the other proteids than that 
which exists in human milk. Again, cows' milk precipitates or 
coagulates very early with the aid of acids and salts; woman's milk, 
quite late, or not at all. Therefore in the infant stomach cows' milk 
does not take up much acid of the gastric juice, and soon coagulates 
in large masses. Woman's milk, on the other hand, takes up a 
large amount of acid of the gastric juice, and coagulates late in 
small masses. These differences in the modes of coagulation in the 
two caseins are of great importance in the study of infant feeding. 

Formerly, the caseins of woman's and of cows' milk Avere believed 
to be identical in composition. Later work (Szontagh) shows that 
the casein of woman's milk is not a nucleo-albumin. Human milk 
is richer in nucleon and lecithin than cows' milk, and contains more 
combined phosphorus than cows' milk in the nucleon. Hence the 
two caseins may be considered essentially different substances, as 
first claimed by Hoppe-Seyler, Hammarstcn, and Wrobelewski. 
Xot only is the casein of cows' milk a substance sui generis, but its 
digestion in the intestine of the infant is conducted with great 
loss. Paracasein and pseudonuclein of cows' milk pass through the 
gut unabsorbed (Knoepfelmacher). The loss in phosphorus to the 
infant is sixteen times as great with cows' milk as with woman's 
milk. This fact is also of great importance in the artificial feed- 
ing of infants. The prevalence of bone disturbances of the severer 
type (rachitis) in artificially fed infants is explained by the absence 
from the food of an element (phosphorus) so important to bone 
nutrition and growth. 

The increase in weight of artificially fed infants also gives us an 
insight into the physiological processes in these subjects. The 

5 



66 



INFANCY AND CHILDHOOD. 



quantity of milk necessary to maintain nutrition is greater than in 
the case of the breast-fed infant. There is always the danger of 
overfeeding an infant on the bottle. The increase in weight is not 
so regular as in the breast-fed infant, as is shown in the following 
table : 



f Weeks 1—2 2—4 4—1 
Increase 4 21 21 



Camerer ) Veeks 
Increase 

Months 1 



B— 12 12—16 16—20 20—24 

22 22 25 22 

24—28 28—32 32—36 36—40 40—52 
13 16 16 9 12 

4 5 6 7 8 9 10 



[Weight 3810 4430 5090 5800 6550 7180 7650 8140 8600 8880 



Koplik {Months 
r t Increase 



1 2 3 


4 


5 


6 


7 


8 


9 


3735 5068 


5285 


5518 


7688 


7223 


8680 


9021 



In the above tables there are shown in grammes not only the 
irregularity in the daily increase, but also the irregularity in the total 
weight. My own cases were examined with a view to determining 
what an artificially fed baby weighs if it is thriving. The figures 
correspond closely to those given by Camerer. 

The following table shows in grammes the daily increase of weight 
of the breast-fed anel the bottle-fed infant : 



Months Ahlfeld 

Momns - (breast). 

1 31 

2 26 

3 24 

4 21 

5 18 

6 15 

7 15 

8 16 

9 9 



Camerer 


Koplik 


(bottle). 


(bottle) 


21 


32.0 


22 


17.4 


22 


23.6 


25 


18.0 


22 


14.2 


13 


11.8 


16 


15.6 


16 


15.1 



The Modification of Cows' Milk for Infant Feeding. 

In order to make clear to the student the rationale of our present 
methods of artificial feeding, it will be of advantage to study the 
development of infant feeding with cows' milk. The casein of cows' 
milk has from the outset been a point of attack. The older methods 
consisted of two or three dilutions of cows' milk. In the first 
month the milk was diluted 1 in 3 ; in the second month, 1 in 2 ; 
in the third month, 2 in 3. These simple methods continued in use 
until Biedert in Germany and Meigs in the United States attempted 
so to proportion the casein, fat, and sugar as to make the mixture 
approach the composition of mother's milk. 

Biedert called his food "cream mixture." It was made in the 
same general way as Meigs's mixture. These men perfected their 
formulas independently of each other, and, strange to say, insisted 
on the same fact — the low percentage of proteids in mother's milk. 



MODIFICATION OF COWS' MILK FOE INFANT FEEDING. 67 



Meigs claimed that the proteids ranged from 1.2 to 1.5 percent. 
Biedert's mixture was constructed to contain — proteids, 1 per cent.; 



tat, 2 to 2.5 per cent.; 



ugar. 



4 per cent. Meigs's mixture contained 



3.5 per cent, of fat and 6 per cent, of sugar. 

Biedert took the cream (0.25 litre) from milk (1.5 litres) that 
had stood one hour. This contained 10 per cent, of fat. AVith this 
he constructed the following formulas : 



No. of mixt- 
ure. 


Cream (10 
per cent.) 

Litre. 


Water. 


Milk- sugar 


Milk. 
Litre. 


Casein. 


Fat. 


Sugar. 




Litre. 


Gramme. 


Per cent. 


Per cent. 


Per cent. 


I. 


1 


3 

8 


18 


— 


(= 1 


2.5 


5.) 


II. 


h 


3 

8 


18 


T.7 


= 1.4 
(= 1.5 


2.6 


5.) 


III. 


k 


3 
8 


18 


8- 


2.6 


5-) 


IV. 


I 


1 


18 


1 


= 1.8 

(=2.1 


2.8 


5.) 


V. 


I 


I 


18 


3 

8 


3 


5.) 


VI. 




I 


12 


•T 


= 2.3 


2.4 


5.) 



If we compare these with Meigs's mixture, we find that Meigs 
constructed only one formula, which contained 1.2 per cent, of 
proteids, 3.5 per cent, of fat, and 6 per cent, of sugar. His method 
was identical with that described above. He used top cream, and 
mixed with it a certain quantity of milk and water (10 c.c. of cream, 
5 c.c. of milk, 10 c.c. of lime-water, 15 c.c. of water, containing 2.2 
grammes of milk-sugar). 

In view of the subsequent trend of infant feeding, these two 
methods are of great interest. The method of Eseherich has also 
been mentioned. It is based on an attempt to calculate by rough 
dilutions of milk the amount of albumin necessary daily for the 
maintenance of nutrition. There are two methods which are prac- 
tically identical — the Heubner-Holfman and the Soxhlet, in each 
of which an endeavor is made to obtain a mixture whose chemical 
equivalents will equal the nutritive calories in mother's milk. 
In both methods the milk is diluted with an equal part of water. 
Heubner uses as a diluent a 6 per cent, sugar of milk solution ; 
Soxhlet, a 12 per cent, sugar of milk solution. The addition of 
sugar of milk is intended to supply the deficiency in fats. Soxhlet 
ha- shown that in the economy, sugar of milk has an equivalent 
caloric energy equal to that of the fat deficit. I have used the mixt- 
ure- for years in a public laboratory and in private practice, and 
have found that they possess the following disadvantages : Infants 
from the first to the third month suffer from the diminution of fat 
and the large amount (1.8 to 2 per cent.) of proteids. The mixt- 
ures are suitable only for older children. AVith our present 
means we can construct mixtures more suitable to the needs of 
infants. This brings us to the consideration of the methods of 
infant feeding elaborated by Rotch. Rotch contended that all 
infants could not be fed on one mixture ; that taking the compo- 



68 INFANCY AND CHILDHOOD. 

sition of mother's milk as a working basis, each infant should have 
constructed for its use a formula which within certain limits 
would be most suitable to its needs. Rotch therefore separates the 
milk from the cream by means of a separator. Working with 
skimmed milk and cream containing 16 per cent, or 20 per cent, 
of fat and a solution of milk-sugar, the constituents of the milk 
are rearranged. By this method an infant can be fed on a mixt- 
ure containing 0.5 per cent, of proteids, 3 per cent, of fat, and 6 per 
cent, of sugar ; or 1.5 per cent, of proteids, 2.5 per cent, of fat, and 
6 per cent, of sugary or any percentage of proteids, fat, and sugar 
that we may wish to give. He also contended that a baby which 
would not thrive on 1.2 per cent, of proteids, might do so on 1.5 per 
cent. The proportion of fat might be reduced or increased as needed 
in the individual case. In other words, the physician should con- 
struct his percentage formula in feeding the infant just as he pre- 
scribes a certain strength of a drug. To obtain these percentages, 
a laboratory is needed, and to-day laboratories for supplying mixt- 
ures to be used in the percentage feeding of infants are to be found 
in all large cities. Though this method of reconstructing milk is by 
far the most rational yet proposed, it has certain inherent defects 
which Rotch and his pupils are trying to overcome. These defects 
are much the same as those of the older methods : 

1. By simply rearranging the proteids, fat, and sugar we do not 
change the proportionate relationship which the casein or caseinogen 
bears to the lactalbumin and other proteids of the milk. 

2. With the exception of a few limited facts and formulas, we have 
no data which with our present knowledge will enable us to know in 
every case when to increase or diminish the proteids and also the fat. 

3. It is contended by Starr, Monti, and others, though denied 
by Rotch, that the process of centrifuging impairs the original deli- 
cacy of the fat emulsion in the milk, and therefore the influence of 
this fat on the coagulation of the casein. 

We cannot enter here into a consideration of the merits of the 
last objection. It is enough to grant at once that the wcyrk of 
Rotch has been of far-reaching importance in infant feeding. It lias 
been a great educator to physicians and a simplifier of former con- 
fusion. We can now obtain good, fresh milk, and it may be modi- 
fied according to any formula. 

The Whey Method of Dilution and Modification. — The prin- 
cipal obstacle to the universal success of the original Rotch method is, 
as stated in (1), that the proportion of the casein or caseinogen to the 
remaining proteids of the cows' milk (cows' milk, five-sixths casein- 
ogen and one-sixth lactalbumin and lactoglobulin, as compared to 
mothers' milk, two-sixths caseinogen and four-sixths lactalbumin 
and lactoglobulin) remains the same. The most rational method 
of overcoming this obstacle is to dilute with whey instead of water, 



BACTERIA IN COWS' MILK; PASTEURIZATION; STERILIZATION. 69 

to use a cream which is highly concentrated for the fat proportions, 
and to use skimmed milk to obtain the caseinogen. 

This method was first proposed by Vigier, and elaborated by 
Monti, of Vienna, in 1897. It really produces a species of 
humanized milk. Monti took a quart of milk, added rennet to it, 
and heated it at 35° C. (95° F.) for twenty to thirty minutes. He 
then filtered off the curdled casein and pasteurized the whey. The 
pasteurized whey contains about 1 per cent, of proteids (lactalbumin 
and lactoglobulin). He then mixed the whey with equal parts of 
milk or with 1 part of whey and 2 parts of milk. He thus obtained 
1.2 to 1.6 parts of casein with 1 per cent, of dissolved proteids in 
the whey. White and Lladd, pupils of Rotch, have still further 
reduced the casein, so that with concentrated cream, skimmed milk, 
and whey they obtain mixtures in which the caseinogen or casein 
bears the same proportionate relationship to the lactalbumin and 
lactoglobulin as it does in human milk. Thus, with a total proteid 
percentage of 1.25, two-thirds is whey proteids (lactalbumin, etc.) 
and one-third casein and caseinogen. The following table shows a 
few of the combinations of caseinogen and lactalbumin obtainable 
at the laboratories (Rotch) : 



Fat. 


Caseinogen. 


Lactalbumin. 


Sugar. 


Per eent. 


Per cent. 


Per cent. 


Per cent. 


1.00 


0.25 


0.25 


4 to 7 


1.50 


0.25 


0.75 


4 to 7 


2.00 


0.50 


0.75 


4 to 7 


2.50 


050 


0.75 


4 to 7 


3.00 or 3.50 


0.50 


0.75 


4 to 7 



AVe have thus arrived at a method by which mother's milk can 
be exactly duplicated. Its success in practice must be left for future 
study. 

Having traced the development of the complex problem of infant 
feeding, we shall now consider its practical application. 

Bacteria in Cows' Milk; Pasteurization; Sterilization. 

By insisting on strict cleanliness of the cow's udder, the hands of 
the operator, and the utensil in which the milk is collected, it is pos- 
sible to obtain milk free from bacteria. Commercially, however, 
this is manifestly impracticable. Even milk collected with great care 
contains bacteria. If these bacteria number 9000 to the cubic centi- 
metre, they will under favorable conditions increase, so that in twenty- 
four hours at ordinary temperatures they will number 5,600,000 
(Miquel). The bacteria chiefly found in milk are the Bacterium 
lactis aerogenes, the Bacillus mesentericus vulgatus (potato bacillus), 
and the Bacillus subtilis. The milk may contain streptococci (Esch- 
erich) from the udder of the animal. It may contain any of the 
various pathogenic bacteria — pneumococci, typhoid bacillus, diphthe- 
ria bacillus, the germs of scarlet fever, measles, or the Bacillus tuber- 



70 



INFANCY AND CHILDHOOD. 



culosis. Milk is an excellent culture-medium for the germs of all 
infectious diseases. 

Milk Acidity. — If milk is not cooled immediately after with- 
drawal and kept cool, it soon shows a marked increase in acid reac- 
tion. This is due to the growth of the Bacterium lactis aerogenes. 
This micro-organism not only turns milk " sour," but by the pro- 
duction of toxins causes disturbances of the stomach and gut of the 
nursing infant. Without entering into details foreign to this work, 
it is sufficient to state that milk for infant feeding should be obtained 
from a herd of healthy cows. Mixed milk is to be preferred to milk 
from one cow. The milk should be carefully collected into utensils 
which have been sterilized. Milk should reach the consumer as 
soon as possible after milking (within twenty-four hours at most). 
After being modified, the milk is divided into portions, each of which 
is sufficient for a nursing. It is then heated, in order that it may 
be kept unchanged for at least twenty -four hours. 

Pasteurization. — This process was perfected by Pasteur. The 
milk is subjected to a temperature of 65° C. (149° F.) for a variable 
length of time, generally half an hour, and then rapidly cooled to 
20° C. (68° F.). An excellent apparatus for this purpose, called 
the Freeman pasteurizer, has been devised by Freeman (Figs. 19, 20). 

Fig. 19. Fig. 20. 





Freeman Pasteurizer. 

If properly carried out, pasteurization destroys all pathogenic 
germs which may be present in the milk. It also destroys most of 
the Bacterium lactis, but will not destroy any sporulated bacteria, 
such as the Bacillus mesentericus vulgatus. 

Sterilization is the process of heating milk to 212° F. (100° C). 
This may be done by means of the Arnold steam sterilizer (Fig. 21), 
or by simply placing the milk in properly corked bottles in boiling 
water. As a rule, the milk is heated for twenty minutes, when it 
is considered sterilized. The milk should then be rapidly cooled. 
The process of cooling prevents the separation of the fat into large 
globules and the breaking up of the natural emulsion of the milk. 



BACTERIA IX COWS' MILK; PASTEURIZATION; STERILIZATION. 71 



Fig. 21. 



Sterilization, as practised with the ordinary sterilizer, will not 
render milk sterile. It will not destroy any sporulated bacteria, 
but will destroy the Bacterium lactis and all 
pathogenic germs. 

As has been stated, milk should be of 
good quality and contain a minimum of bac- 
teria before being submitted to any heating 
process, for neither pasteurization nor ster- 
ilization will make milk which is decomposed 
fit for use. Both procedures are simply 
means which enable us to keep milk un- 
changed for a longer or shorter time. 

The chief objections to sterilization of 
milk are that the casein is made less soluble, 
that the flit is separated iu the form of but- 
ter, and that the milk has a " boiled " 
flavor. According to some authorities, ster- 
ilized milk which has been subjected to a 

temperature of 212° F. (100° C.) is less Arnold Steam Sterilizer. 

digestible than pasteurized milk that has been heated to 149° F. 




(65° C). 

Nitrogen taken 
in milk. 
Grammes. 
First infant — 

Pasteurized milk 10.9209 

Sterilized milk 13.7449 

Raw milk 5.3914 

Second infant — 

Boiled milk 32.643 

Sterilized milk 30.969 



Nitrogen remaining 
in feces. 
Per cent. 

4.6 
4.9 
3.4 



4.5 
4.3 



The table given above shows the comparative digestibility of raw, 
pasteurized, and sterilized milk (Koplik), as indicated by the per- 
centage of nitrogen remaining in the feces of the infant. These ex- 
periments were performed by feeding the same infant with raw and 
heated milk. The results showed that, although the differences are 
slight, they are in favor of milk subjected to little or no heat. Doane 
and Price have confirmed these results by experiments on the calf. 

The part played by sterilized milk in the causing of scurvy 
has been elsewhere considered. Without entering deeply into a 
question which remains to-day rather unsettled, it may be said that 
tlie majority of experienced men believe pasteurization to be the 
less objectionable of the two methods. During the winter and 
spring months pasteurization answers all purposes. During the 
-ummer, if milk is transported not too great a distance and can be 
obtained within twelve hours of milking, pasteurization with subse- 
quent packing in ice will keep it unchanged for twenty-four hours. 
Among the poor of large cities it is not always possible to obtain 



72 



INFANCY AND CHILDHOOD. 



the milk early. Even if it is obtained fresh, the ignorance and 
carelessness of these people is so great that I have found it safer to 
sterilize the milk during the heated term. In this way gastro- 
enteric disturbances are avoided. On the other hand, milk obtained 
from reliable sources and carefully pasteurized within a few hours 
of the milking can be kept on ice unchanged for twenty-four hours 
in the summer. During the heated term we should never lose sight 
of the fact that pasteurized milk, if not kept on ice, increases in 
acidity and causes gastro-enteric disturbances. 

Raw Milk in Infant Feeding. 

Some physicians, in order to avoid the objections to pasteuriza- 
tion and sterilization, have proposed the use of raw milk in infant 
feeding. That is to say, the milk, after modification, is not heated, 
but is kept on ice until needed. I have not been able to reach any 
conclusion on this point. Any unheated animal food is distasteful, 
no matter how great the care taken in its handling. It is noteworthy 
that infants who have suifered from scurvy will thrive on raw 
milk, while other infants will not. Adults with whom raw milk 
will not agree, tolerate well-heated or boiled milk. I have occasion- 
ally seen infants in whom raw milk, no matter how fresh, caused 
acid movements and green curds in the stools. Exceptional cases 
are met with in which pasteurized milk causes movements which are 
alternately fluid and formed in character. In these cases sterilized 
milk is well borne. 

The Nursing Bottle. 

The best form of bottle is one that has very little neck, a wide 
mouth, and not much shoulder at the neck, so that it 
may be easily cleaned. These requirements are met 
by the Freeman bottle (Fig. 22). When filled, the 
bottles are corked with non-absorbent cotton. They 
are corked loosely, so that the steam may escape. 
If the cotton is jammed tightly into the bottle, the 
cork will blow out in heating. After the nursing, the 
bottles are filled with a saturated solution of washing 
soda and allowed to stand a few hours. They are 
then washed both externally and internally, and 
drained dry. Any residue of milk remaining after a 
nursing should not be utilized for another nursing. 
Nipples should be boiled once daily for ten min- 
utes, and washed with hot water after each nursing. 

Before feeding, the bottle of milk is warmed to 
105° F. (40.5° C), so that the milk may not chill 
Nursing bottle the stomach of the infant and thereby suspend diges- 
modei e Freeman tive processes. 



Fig. 22. 




AMOUNT OF BREAST MILK CONSUMED BY THE INFANT. 73 

Quantity to be Fed to the Infant. 

The quantity of milk to be given at eaeb feeding has been vari- 
ously estimated. It is evident that the capacity of the stomach alone 
is a crude and most unscientific standard, nor is the age of the 
infant in itself a guide. More rational is the method which takes 
into consideration not only these data, but also the normal quantity 
of milk taken by a breast-fed infant daily and at each feeding. If, 
in addition, we can calculate the amount of albumin or proteids and 
tat necessary per kilogramme of the body weight to maintain nutri- 
tion, we shall have the most satisfactory method of determining the 
quantity of milk to be taken daily by the infant and the quantity 
to be given at each feeding. This method was first proposed by 
Biedert, and applied by him and Escherich. It was found that the 
nutrition of the infant could not be maintained by an amount of 
proteids of cows' milk equal to that taken in the breast milk. 
In other words, the proteid equivalent could be obtained, but 
the other constituents (fat, etc.) were at fault as well as the 
daily quantity of food. Escherich' s own figures give a greater daily 
percentage of proteids than is found in mother's milk. On the other 
hand, the recent modifications of milk proposed by Backhaus, Rotch, 
Monti (whey mixture), White and Lladd give promise that the 
ideas of Biedert and Escherich may be carried out. 

Amount of Breast Milk Consumed by the Infant in Twenty- 
four Hours. 

Camerer has collated and analyzed the results obtained by 
Ahlfeld, E. PfeifFer, AVeigelin, and Hahner, as to the quantity of 
breast milk taken daily by an infant. The method of ascertaining 
the figures recorded by these authors was to weigh the infant 
before and after nursing. Camerer gives the following table : 

Dav. 



1st. 2d. 3d. 


4th. 5th. 


6th. 7th. 10th. 


14th. 


30 130 240 


290 330 


305 400 450 


500 




Amount of 


Milk Taken. 




Middle 2d week. 4th week. 
Minimum. . . 210 380 
Medium ... 440 580 
Maximum . . 540 810 


7th week. 10th week. 

520 600 

770 800 

1040 1170 


20th week 

700 

900 

1150 



It is noteworthy that on the first day of life the infant observed 
by Camerer nursed three times, and seven times in each twenty- 
four hours from the second to the fourteenth day. Each nursing 
occupied a mean of about twenty to twenty-five minutes. These 
data are of value in prescribing for the artificial feeding of infants. 



74 



INFANCY AND CHILDHOOD. 



Number of Nursings Daily, with the Necessary Quantity of 
Each Feeding, in Artificially Fed Infants. 

If we now attempt to apply the knowledge acquired in the study 
of the feeding of the breast-fed infant to the artificially fed infant, 
we meet with the following obstacles : Cows' milk taken in the same 
quantities is not so completely used up by the economy as breast 
milk. There is much more waste, as has been shown by Knoepfel- 
inacher and Camerer. This waste is chiefly caused by the fail- 
ure to consume the casein and fat. The stools also of the bottle- 
fed infant are more numerous and of greater total bulk than is the 
case with the breast-feel infant. Knoepfelmacher has shown that 
the waste in the gut of phosphorus in cows' milk is sixteen times as 
great as the waste of that element in breast milk. In view of the 
lack of definite knowledge on these points, the quantities of modified 
cows' milk given at each feeding are still determined by experience 
aloue. We have, it is true, been aided in this work by the study 
of the absolute quantity of proteids and fats necessary to the main- 
tenance of nutritiou. 



Table showing the Number of Feedings and Quantities of Modified Milk to 
be given to Artificially Fed Infants. 



Age. 



First day 

Second day 

Third day 

Fourth day 

Seventh day 

Second week 

Fourth week to first month . 

Two months 

Three months 

Four months 

Five months 

Six months 

Seven and eight months . . 
^Nine months 



Number of feed- 'Quantity at each Total to be given 
ings daily. feeding. in 24 hours. 



8 

8 

8 

8 
7 or 8 

7 

7 
6 or 7 

6 

6 

6 



C.c. Oz. 

10 

20 

30 1 

40 

50 

60 

60 

90 
120 
150 
180 6 
210 7 
240 8 
250 U 



C.c. 

80 

160 

240 

320 

400 

480 

480 

720-630 

840 
1050 

1080-1260 
1260 
1440 
1500 



Oz. 

1 

5J 

8 

lOf 
13J 
16 
16 

21-24 
28 
35 

36-42 
42 
48 
50 



The increase in the amount of milk from the seventh to the 
ninth month is not so apparent, since at this period we, as a rule, 
begin to feeel cereals in addition to the milk. 



Composition of the Food. 

AVith the healthy infant there is little need of frequent changes 
of formulas. There are certain rules which must be strictly adhered 
to in order that the infant be not upset at the beginning : 



HOUSEHOLD MODIFICATIONS OF MILK FOR FEEDING. (b 

The total amount of proteids in the cows' milk mixtures must 
be very low for the newly born infant, certainly not exceeding 0.5 
per cent, during the first week. After this time the proteids are 
increased to 1 per cut., and kept at this point until the third month, 
when they are increased to about 1.5 per cent., and kept there until 
the ninth month. In vigorous infants of heavy weight we may 
increase the proteids at the sixth month to 2 per cent., but I have 
never found it necessary to go beyond this limit. 

Fats. — The fats in the first few days after birth should be low 
in amount (2-2.5 per cent.). After the second week to the third 
month I have always given about 3 to 3.5 per cent, of fat. The 
reason for this is that during this period we find that the infant 
does not increase in weight as it should unless the fats are high. 
After the third month the fats may be reduced to 2 or 2.5 per 
cent, with most infants. This proportion is continued until the 
ninth month without change. Unless there is some special indi- 
cation, I would construct the following percentage formulae for 
normal infants : 



Age. Proteids. Fats. Sugar. 



One to seven days 0.50 

One week to three months 1.00 

Three months to six months \\ -,'en 

Six months to nine months -j | 9 '™ 




Household Modifications of Milk for Infant Feeding. 

The accuracy of the laboratory cannot be attained in home modi- 
fication of milk. Xo matter how carefully the milk is put together, 
there are details which are impracticable at home. In the laboratory 
the milk-supply is controlled ; the milk has a definite composi- 
tion ; the modification is more accurately carried out. On the other 
hand, many infants do quite well on household modifications, 
which are crude as compared with those of the laboratory. For 
sick children and in convalescence it is of great value to obtain a 
modification whose composition is definite and accurate. It can 
thus be known what mixture will agree with the patient. On the 
recovery of the patient we often find that a mixture approximating 
that of the laboratory can be made up at home, and that the infant 
will thrive on it. Laboratories are not always accessible. We 
should, therefore, have at our command methods which will replace 
those of the laboratory if only in a rough way. There have been 
devised many methods of so-called home modification. They have 
the merits and faults of mathematical formulas — they are rarely at 



76 INFANCY AND CHILDHOOD. 

our finger-tips. I have not had an extensive experience in the use 
of these formulas. There are two very practical and easily remem- 
bered methods of home modification. One is that of Chapin. 
Chapin found that in milk which is put up in bottles the cream 
sets so that its composition is the same within certain limits. In 
city milk, the first 9 to 11 ounces of cream from the top of the 
bottle will contain 12 per cent, of fat. If 16 ounces are taken 
from the top of the bottle, the cream will contain about 8 per cent, 
of fat. 





Composition. 




Top cream 




Amount of foe 




Age. 


Proteids. 


Fat. 


Sugar 


>d daily. 


1-7 days . . 


. . 0.50 


2.0 


6.0 


2oz. 


diluted 6 1 


imes. 


360c.c. 


12 oz 


1 week to 3d month 1.00 


3.5 


6.0 


7 " 


« 4 


u 


840. 


28 " 


3-6 months . . 


. 1.12 


2.6 


6.0 


14 " 


" 3 


" 


1200. 


42 " 


6-9 months . . 


2.00 


6.0 


23 " 


" 2 


u 


1400. 


46 " 



(Two bottles of milk required in order to get requisite amount of cream.) 

The percentages given above are not absolutely correct, They 
will vary with the proportion of cream in the milk. They are as 
correct as any home modifications. We can start infants on these 
percentages and increase or diminish the fat or proteids if the infant 
does not thrive. In the table just given it is assumed that cows' 
milk has the composition of proteids 3.5 per cent., fats 3.6 to 4 per 
cent,, and sugar 4 per cent. 

The other method of which I have made use requires cream con- 
taining 16 per cent, of fat. With ordinary milk and a 6 per cent, 
solution of sugar of milk, assuming the composition of cows' milk as 
above, we first calculate the proteid composition of the mixture, 
diluting with the 6 per cent, sugar of milk solution. This gives 
us, if we dilute the milk, a mixture having the absolute proteids and 
a certain percentage of fat and sugar. The sugar is ignored. We 
then add to this the requisite amount of the 16 per cent, cream 
to bring the fats up to the required strength, allowing for the 
fat already in the dilution. This is simply a matter of calcula- 
tion, and can be worked out by anyone if the required materials are 
at hand. In cities the laboratories will furnish the 16 per cent, 
cream. In other places a gravity or top cream containing 12 per 
cent, of fat can be utilized instead. The following table is con- 
structed with 16 per cent, cream, ordinary milk, and 6 per cent, 
solution of sugar of milk. 

The practitioner will find that the above milk modifications can 
be utilized in most normal cases. 

All modifications of cows' milk must be alkalinized with lime- 
water. This is the most practical and accessible alkali. A tea- 
spoonful of lime-water is allowed to 8 ounces of milk. 



INFANT FOODS. 



77 



Konig's Analysis — Average Coivs' Milk — 87.1 Water, 3.5 Proteids, 3.6 Fat, 

4 Sugar. 

Modification. 

p Dailv total mian- Constituents, 16 per cent. 

Age Jgds Fat- Sugar. tV needed cream, milk, 6 per cent. 

teias « tit> needed, solution sugar of milk. 

C.c. 
(Cream (16 per ct.) 34.00 

1-7 days 0.5 2.0 G.O Up to 350 c.c. \ Milk (whole) . . 16.00 

12 ounces. (. Water! sugar 6^ ) 300.00 

( Cream 140.00 

1 week to 3 months 1.0 3.5 6.0 Up to 840 c.c. \ Milk . . . . .140.00 

28 ounces. (. Sugar solution . 560.00 

( Cream 120.00 

3-6 months .... 1.2 2.6 6.0 Up to 1200 c.c. \ Milk 280,00 

40 ounces. ( Sugar solution . 800.00 

I Cream 50.00 

(3-9 months .... 1.7 2.0 6.0 Up to 1400 c.c. Milk ..... 650.00 

46 ounces. ( Sugar solution . 700.00 



Infant Foods. 

There is no infant food, except those modifications of cows' milk 
described elsewhere, which can be utilized as a substitute for the 
breast with any success. In the case of older infants and young 
children the infant foods of a certain type may be utilized as adjuncts 
to the baby's dietary. This is done much as we would utilize any 
cereal. 

Infant foods are divided first into those which are cereals in 
a pure state or subjected to heat, and thus dextrinized. To this 
class belong Imperial granum and Ridge's food. The other large 
class contains (a) milk mixed with cereals or (b) with forms of malt. 
In (a) are the foods of the Nestle food class, which contains evap- 
orated and dried milk and cereal. In (6) are all the malted milk 
foods, such as Horlick's, malted milk, etc, Liebig's infant food in 
dry state. 

If we study all these foods, including the condensed milk, Ave 
shall see that they show a deficiency of fat and an excess of carbo- 
hydrates. They should not therefore be used exclusively for a 
long time. Condensed milk also contains so much sugar that it 
causes acid dyspepsia. There are preparations of condensed milk 
made up without sugar. These are likely to decompose, and even 
when fresh have the disadvantages of all the artificial foods. A 
number of cases of scurvy resulting from the prolonged exclusive 
use of condensed milk and infant foods have been reported. 

On the other hand, I have utilized the infant foods which do not 
contain any milk as adjuncts to milk modified or whole. In the 
treatment of enteritis, both of the acute and the subacute type, it is 
essential to give temporarily some food which does not contain milk 
in any form. With some form of cereal food such cases are very 
successfully tided over the period of subacute enteric catarrh. The 



78 



INFANCY AND CHILDHOOD. 
Foods for Infants. 



Name. 



Cam rick's soluble food . . . . 

Horlick's food 

Horlick's malted milk .... 
Hubbell's prepared wheat . . . 

Imperial granum 

Just's dietetic food 

Lactopreparata 

Liebig's soluble food 

Mellin's food 

Milkine 

Nestle's food 

Nursing meal 

Nutrico food 

Ridge's food 

Wagner's infant food 

Wells, Richardson & Co.'s lac- 

tated food 

Zimmerman's health food . . . 



3.12 
3.64 
2.87 
5.93 

10.57 
4 83 
3.28 

22.03 
3.93 
2.74 
2.37 

10.84 

11.87 
8.87 
5.07 

2.94 
0.79 



6.26 
2.01 
7.81 
1.19 
1.32 
0.79 
6.26 
0.08 
2.04 
7.12 
4.94 
2.36 
4.38 
1.67 
10.91 

2.67 
1.33 



Carbohydrates. 



16.32 
11.28 
16.61 
14.81 
19.37 

3.85 
22.48 

3.32 
11.87 
13.37 
11.04 

6.22 
13.40 
13.37 
14.81 

13.22 
11.16 



56.62 
63.14 
59.43 
16.16 
15.42 
70.60 
58.89 
76.38 
59.45 
61.19 
43.75 
44.66 
9.75 
8.32 
37.91 

28.84 
14.73 



14.44 
17.28 
10.95 
60.86 
51.88 
18.31 
7.21 



0.22 
0.73 
0.52 
0.31 
0.31 
0.51 
0.81 



17.71 
13.63 
35.73 
32.96 
57.83 
66.35 
28.91 

48.45 
63.97 



0.53 
0.63 
0.47 
0.63 
0.61 
0.81 
0.37 

1.37 
0.71 



3.02 
1.92 
1.81 
0.44 
1.13 
1.11 
1.07 
1.41 
4.47 
1.32 
1.61 
2.31 
1.77 
0.61 
2.01 

2.51 
1.31 



(Bulletin U. S. Department of Agriculture, modified by the author.) 

infant foods, made up of cereals dextrinized or unchanged, are given 
in solution, and are ve*y well borne. After the ninth month infants 
need some cereal added to the milk. In such cases not only is 
barley or some infant food which is a cereal well borne, but the 
cereal aids in breaking up the casein, which is at this period 
given to the full amount present in cows' milk. Infants whose 
movements are not satisfactory on milk alone do very much better 
if a cereal is added to the milk at this time. 



Dextrinized Gruels as an Infant Food. 

Chapin in this country and Keller in Breslau have lately advo- 
cated the addition of dextrinized cereals to milk in order to facilitate 
the digestion of the casein. Instead of using water as a diluent, 
Chapin adds these dextrinized gruels to the milk for both healthy 
and sick infants. Keller has advocated the use of these gruels 
with sick infants, especially those of the marantic type. 

The majority of pediatrists use no other diluent for the milk 
than water. We shall therefore only elucidate this method of infant 
feeding as it applies to sick infants. These mixtures are dextrinized ; 
in this they differ from the former barley-flour mixture of Jacobi, 
in which a simple dilution of barley was made in water. This was 
used as a diluent. In the present method diastase, either pure or in 



DEXTRINIZED GRUELS AS AN INFANT FOOD. 79 

the form of a malt extract containing diastase, is added to the cereal 
solution. Chapin takes a tablespoonful of flour, adds this to a pint 
and a half of water, and boils the mixture for fifteen minutes. He 
then adds a teaspoonful of a solution of diastase. The gruel becomes 
thin and is dextrinized. It is added to the milk as a diluent in the 
quantity required. 

Keller utilizes the old formula of Liebig in making a malt 
extract. To this malt extract potassium carbonate is added as a 
normal salt. 100 grammes of this malt extract are added to 500 
grammes (1 pint) of water and dissolved. This is solution No. 1. 
He then suspends 50 grammes of wheat flour in 500 c.c. of milk. 
The wheat flour and milk solution is strained. It is then added to 
the malt extract solution, and both are slowly brought to a boil, 
being stirred constantly over a slow fire. The mixture is put up in 
bottles each containing six ounces, corked and kept cool. This 
mixture contains the dextrinized cereal, malt sugar (the most assim- 
ilable form of sugar for the infant), and the proteids of the milk. 
Liebig malt extract, used by Keller, contains : maltose, 57 per cent.; 
dextrin, 12.4 per cent. Wheat contains 66.8 per cent, of starch, 
7.5 per cent, of dextrin, and a small amount of dextrose. By the 
action of the ferments in the malt extract the starches are converted 
into sugars. In this manner a number of easily assimilable and 
easily absorbable substances are introduced into the economy. The 
action of these processes on the casein coagulation seems to favor its 
assimilation. 

I am not prepared to pass a final opinion on the merits of this 
method of feeding. I have tried it in about fifty cases of subacute 
and chronic enteric catarrh, and have seen infants thrive and increase 
in weight on this food. In subacute enteric catarrh, in which milk 
in simple dilution is not assimilated, this food will be well borne and 
the diarrhoea will subside. Cases of infantile marasmus in older 
infants and young children improve on this form of food, when 
the simple milk modifications of Rotch fail. Keller has found that 
the acid intoxication which exists in the gut of these marantic infants 
i> neutralized by this food. The increased ammonia in the urine 
of these infants is an index of this form of gut poisoning. This 
ammonia diminishes or disappears from the urine on the adminis- 
tration of these dextrinized gruels. Keller has given these infants 
malt extract without cereals, but failed to obtain any increase of 
weight. I have found that the cases best adapted to the use of this 
food are atrophic infants from six to seven pounds in weight, too 
old for a wet-nurse ; also infants who after the twelfth month either 
refuse to take milk food in any form or do not thrive and are sta- 
tionary in weight. After increasing in weight and taking the foods 
for two or three months, it is best to wean the children gradually 
from the food and to accustom them to simpler milk modifications 



80 INFANCY AND CHILDHOOD. 

and other articles of diet. I have experienced no difficulty in accom- 
plishing this. Infants if kept too long on this malted food will 
develop scurvy. 

Other Foods. 

Barley-water. — Barley-water is used as a diluent with normal 
infants and in forms of diarrhoea. With older infants barley may 
be utilized in the form of a pap, as may any other cereal. 

Barley-water is made as follows : A teaspoonful of Robinson's 
patent barley is added to a pint of cold water in a saucepan. The 
barley is well dissolved. It is placed on a slow fire and stirred 
until the whole becomes clear and of the consistency of thin starch 
paste. Older infants take the barley in much more concentrated 
form with relish. 

Albumin-water. — Albumin-water is utilized chiefly in cases of 
acute stomach and intestinal disorder in which some nutritious 
and easily assimilable food is needed ; albumin-water is then very 
useful. The white of one egg is dissolved in 8 ounces or a pint 
of water which has been boiled and then cooled. The solution is 
strained. 

Peptonized Milk. — This is milk in which partial or complete 
digestion of the casein has been accomplished by the addition of 
peptonizing extracts (Ex. pancreatis) and soda in dry form. These 
peptonizing tabes are sold in the shops (Fairchild\s). Milk thus 
prepared is called peptonized milk or humanized milk. The use of 
these forms of food can at best be only temporary. As a rule, the 
children dislike the taste, which is bitter. In other cases the infants 
do not increase in weight under its use, and the atrophic conditions 
are perpetuated. I have utilized these peptone preparations but 
little. Some of my cases have taken the foods thus prepared for 
a time, and then have had to be fed on other milk modifications. 

Koumyss and Matzoon have but a very limited field in infant 
feeding. 

Expressed Beef-juice. — This food is very useful in forms of 
diarrhoea and dysentery. A half pound or a pound of chopped lean 
meat is made into an oval flat mass, placed on the broiler and 
browned. The juice is then expressed with a small meat press, 
mixed with equal parts of barley-water and salted to suit the taste. 

Acorn Cocoa. — Acorn cocoa is a preparation made in Germany, 
and is for sale in the shops. It is useful in cases of diarrhoea and 
intestinal diseases in which it is advisable to suspend the use of 
milk, and may be given for days. It contains fat, nitrogenous 
matter, and tannic acid. A teaspoonful is dissolved in 8 ounces 
of cold water. The preparation is given in the same manner as 
milk. 






FEEDING FROM THE NINTH TO THE TWELFTH MONTH 81 

Feeding of Breast-fed Infants and of Bottle-fed Infants after 
the Sixth Month. 

Camerer has shown, that the secretion of the breast-milk 
reaches its highest limit in quantity and quality in the sixth month 
of lactation. In many cases it then diminishes in quantity and 
quality. If the infant gains steadily after the sixth month, nothing 
additional is given. If, however, the increase of weight is not satis- 
factory, we may at this period begin the daily administration of one 
or two bottles of modified cows' milk up to the ninth month, the 
time when the baby is weaned. Ou the eruption of the incisor teeth 
the baby, generally at the seventh month, is allowed a cereal in the 
shape of some prepared barley or cracker cr rusk {Zwieback) to 
nibble upon once a day. The barley is omitted if the infants are 
inclined to be constipated. I find that one rusk (Zwieback) or 
cracker daily is sufficient. As to cereals, the same procedure is fol- 
lowed with the bottle-fed infant after the teeth have appeared or 
after the seventh or eighth month. 

Feeding from the Ninth to the Twelfth Month. 

Breast-fed Infants. — Weaning. — It is not advisable to wean 
infants at the outset of the summer season, even though they must 
be kept at the breast a few months longer. The infant must not be 
wholly deprived of the breast in the warm season. If the bottle 
milk disagrees with the baby, it will go very hard with it should 
weaning have been accomplished at the outset of the summer. It 
takes about eight weeks to wean a baby completely. If the baby has 
had the benefit of one or two additional bottles daily from the sixth 
month, the process is comparatively simple. If, however, the infant 
has been kept on the breast exclusively until the ninth month, wean- 
ing is often very difficult. The infant will not take the bottle so 
long as there is a breast at its disposal. The only way out of the 
difficulty is to dispose of the nurse and thus force the infant to take 
the bottle. This requires much moral courage on the part of the 
physician. In those cases in which the mother nurses the baby we 
cannot always gain her co-operation in denying the breast to the 
infant. The difficulties of weaning in such cases will be great. In 
weaning, I give those modifications of cows' milk which contain from 
1 to 1.2 per cent, of proteids and from 2 to 2.5 per cent, of fats 
until the infant is fully weaned. I then increase the strength of 
the milk to that given to the bottle-fed baby at the ninth month. The 
bottle-fed baby at this time is given almost pure milk. It is well 
to mix the milk with a small quantity of water (1 ounce of water 
to 7 ounces of milk). In addition, from the ninth to the twelfth 
month both breast-fed and bottle-fed infants are given cereals in the 
shape of pa]), barley, or granum, or rusk (Zwieback) or crackers 

6 



82 INFANCY AND CHILDHOOD. 

twice daily. Some mothers give these infants an ounce of expressed 
beef-juice with barley once a day. Infants relish this change. 

Feeding from the Twelfth to the Eighteenth Month. 

From the twelfth to the eighteenth month I allow the infant the 
following dietary : 

Milk, a quart and a half pint to a pint daily. 

Cereals. Rusk [Zwieback) or crackers, two of each a day. 
Sponge-cake in shape of long sugared slices. Barley, granum, or 
oatmeal, strained, in form of pap, once a day. 

Eggs. One soft-boiled egg a day. 

Beef-juice, expressed, with barley-water. 

The above is divided up into five meals daily. 

Feeding from the Eighteenth Month to the End of the Second 

Year. 

Five meals in the twenty-four hours, consisting of : 

Milk, one quart (outside limit). 

Eggs, soft-boiled, one or two daily. 

Soup or beef-juice. 

Meat, beef, about 2 ounces. 

Vegetables. 

Cereals. 

Milk. Some children will take more or less, some very little 
milk at this period. The eggs are boiled for two minutes. Most 
children will require only one a day. 

Soups. The quantity of beef-juice or soup should not exceed 
4 ounces. 

Meats. The ordinary boiled meat, inside of a lamb chop, small 
piece of steak, roast beef, chi ^ken. Gamey meats and fat meat, such 
as mutton, ham, pork, are to be avoided. 

Vegetables. Potatoes, peas, beans, carrots ; all should be given 
in puree form. 

Cereals. Barley, rice, granum, wheatena, oatmeal, rusk (Zwie- 
back), crackers of all kinds, cocoa, farina. 

Fruits. Orange (juice), ripe apples, and pears. 

To be avoided. Vinegar, cabbage, salad, coffee, tea, wine, spices ; 
too great an amount of amylacea. 

A dietary from the eighteenth month to the end of the fourth 
year might be formulated as follows : 

First breakfast, 8 a.m.: 250 c.c. (8 ounces) of milk ; 60 grammes 
(12 ounces) of bread or crackers. 

Second breakfast, 10.30 a.m.: 180 c.c. (6 ounces) of milk ; 
1 rusk (Zwieback) ; juice of orange. 

Dinner, 1p.m.: 120 grammes (4 ounces) of soup ; 75 grammes 
(2.5 ounces) of meat ; vegetables. 



THE FEEDING OF SICK INFANTS AND CHILDREN. 83 

Afternoon lunch, 4 p. m. : 250 c.c. (8 ounces) of milk or cocoa ; 
rusk {Zwieback) or cracker. 

Supper, 6.30 or 7 p. M. : soft egg ; 250 c.c. (8 ounces) of milk ; 
cracker, toasted bread, or fariua in milk. 

Candy. I allow one or two pieces of candy, generally good 
chocolate, daily to older children. 

From the third to the sixth year of life the diet should be mostly 
mi id or semifluid. The basis of all such diets should be milk, milk 
soups, eggs, meat, butter, cocoa, breadstuffs, vegetables, and fruits. 
The number of meals a day should be five. 

The following is a schedule of a liberal diet at this time : 

First breakfast, 8 a.m.: 330 c.c. (11 ounces) of milk; 100 
grammes (3.5 ounces) of bread. 

Second breakfast, 10.30 a. m. : 330 c.c. (11 ounces) of milk; 90 
grammes (3 ounces) of bread; 10 grammes (J ounce) of butter; 
juiee of orange. 

Dinner, 1 p. m. : 180 c.c. (6 ounces) of soup; vegetables; 90 
grammes (3 ounces) of meat. 

Afternoon lunch, 4 p. M. : 330 c.c. (11 ounces) of milk; 90 
grammes (3 ounces) of bread. • 

Supper, 7 p. m. : 250 c.c. (8 ounces) of milk or mixed with 60 
grammes (2 ounces) of cereals. 

This is a liberal diet. Some children will not take as much milk 
as is here prescribed. Eggs have not been included, nor certain addi- 
tional fruits which it may be allowable to give. This form of diet, 
with some slight modifications, is suitable up to the tenth year of 
life. The main object of all dietaries, after the eighteenth month, is 
to mix the carbohydrates, fats, and albuminoids in rational propor- 
tions. The following table, by Camerer, shows this distinctly : 

{Second to Five to Seven to 

fourth vear. six vears. ten vears. 

12.7 kilo. 1 18.7* kilo. 24 kilo. 
Total food (daily) . . 1183. grammes. 1517. grammes. 1699. grammes. 

Albumin 46. 64. 67. 

Fat 39. 46. 32. 

Carbohydrates ... 117. 197. 251. 

Water 957. 1200. 1333. 

The Feeding of Sick Infants and Children. 

The feeding of sick infants is considered under the headings 
of the various diseases. It must always be borne in mind that 
infants and children, if left to their own resources, would take 
either very little nourishment or too much. In certain marantic 
conditions infants will take very large quantities of food if it is 
given to them. The infant's cries are interpreted by the mother as 
being due to hunger, when they may be due to colic or intestinal 
1 Kilo equals 2.2 pounds. 



84 INFANCY AND CHILDHOOD. 

distention. In these cases the mother gives too great a quantity of 
food, and the infants suffer from dilatation of the stomach. In 
typhoid fever, pneumonia, or other acute disease the patient, if fed 
at long intervals, takes but little food. I am in the habit of giving 
such infants or children small quantities at short intervals. If the 
infant takes a small quantity at each feeding, the aggregate amount 
in twenty-four hours is sufficient to maintain nutrition. 

After operations, such as those for empyema, infants and chil- 
dren must be carefully and systematically fed up in order that they 
may combat the ravages of disease. The necessity of careful feed- 
ing is seen in typhoid fever in the fifth and sixth weeks, at which 
time there is great emaciation and the temperature has dropped to 
the normal. If we fail to feed up the patients, they remain 
emaciated and show slight inanition temperatures. On the other 
hand, we must not give large quantities of indigestible food. We 
must choose the foods carefully. Convalescents can take in twenty- 
four hours much larger quantities of food than the normal, healthy 
child. The quantity given at each feeding should be smaller than 
in health. The nitrogenous foods, such as milk and eggs, and also 
sugars, starches, and cereals of all kinds, are easily assimilable. 
Alcoholics, when given, should be well diluted. Rectal feeding is 
contraindicated in diarrhceal conditions and states of rectal intol- 
erance. On the other hand, if the stomach rejects food repeatedly, 
it is well to give that organ complete rest. Under such conditions 
even water is not introduced into the stomach. The patient is fed 
for twenty-four hours or more per rectum. 

Leading Authorities Quoted in Chapter I. 

Ahlfeld: Ueber d. Ernahrung. d. Saugl., etc., 1878. 
Alix and Vierordt: "Temperatures," Gerhardt's Hand-book, vol. i. 
Backhaus : " Milch Analyse," Berlin, klin. Wochenschr., 1895. 
Baginsky, A. : Antipyrese, etc., Berlin, 1901. 
Budin, P. : Le Nourisson, Paris, 1900. 
Camerer, W. : Der Stoffwechsel des Kindes, etc., 1894. 
Cantani: ''Cholera Behandlung," Berlin, klin. Wochenschr., 1892. 
Chapin, H. D. : N. Y. Med. Jour., Februar}', 1901. 
Conrad, F.: Die untersuch der Frauenmilch, 1880. 
Doane and Price : Maryland Agricul. Bull., 77. 
Eross, Julius: Ueber die Sterblichkeit Cong. Hygiene, 1894. 
Escherich: " Morbiditat," etc., Jahrbuch. fur Kinder, dritte folge, Bd. i. Heft 1. 
Epstein, A.: ''Cholera Infantum," Henoch Festschrift, 1890. 
F el ding ; "Form des Beckens," Arch. f. Gyn., Bd. x. 
Fnurnier: Syphilis Hered. tarda, 1886. 
Herz, P.: Dissertation, Klin, untersuch. neugeb., 1900. 
Keller: Malzsuppe, Jena, 1894. 
Knopf "elmacher : Ernahrung mit Kuhmilch, 1894. 

MacDoncdd: "Experimental Study of Children," U. S. Bureau of Education, 1899. 
Meigs, A. V. : Milk Analysis and Infant Feeding, Philadelphia, 1885. 
Preyer: Die Seele des Kindes, Leipzig, 1890. 
Schlichter: Untersuch. u. Wahl der amme, Vienna, 1894. 
White and Lladd: Phila. Med. Jour., February 2. 1901. 
Wrobeleicski, A. : Beitrag zur Kennt. des Frauen Caseins, 1894. 



CHAPTER II. 

PREMATURE INFANTS— DISEASES OF THE NEWBORN 
INFANT— INJURIES INFLICTED DURING BIRTH. 

PREMATURE INFANTS. 

Prematurely born infants may be congenitally weak, although 
they are not always so. The organs, and especially the lungs, are 
unformed and their functions are incompletely performed. The 
body is spare or emaciated ; the skin is soft, delicate, uniformly 
red, and transparent, showing the bloodvessels. The infant does 
not cry, but rather whimpers ; the respiration is scarcely perceptible. 
The thorax does not move, and there is marked muscular inertia. 
The limbs hardly move ; the infant lies in a torpid condition. It 
often does not swallow its food. The heart-beat is feeble ; there 
may be oedema of the extremities ; and the intestine and stomach 
are easily irritated. The liver performs its functions imperfectly, 
giving rise to icterus. The delicacy of the skin exposes it to irrita- 
tion, with resulting formation of erosions and sclerema. The tem- 
perature in the rectum is below the normal, and ranges from 86° 
to 95° F. (30° to 35° C). 

Management of Premature Infants. — The treatment of a 
premature infant born asphyxiated is at first much the same as that 
detailed in the section on Asphyxia of the Newborn. In most 
cases our efforts should be directed toward maintaining the body 
temperature, nursing the infant properly, and stimulating the heart 
and respiration. With some infants at the eighth month little more 
is necessary than to wrap them up snugly and maintain the sur- 
rounding temperature at the necessary elevation by means of 
warm bottles. In most cases the task of constantly maintaining a 
temperature of from 86° to 98.6° F. (30° to 37° C.) is not easy 
unless resort is had to an incubator. That this maintenance of an 
equable high temperature is of importance has been shown by 
Schmidt. This author proved that loss of body weight could be 
brought about by rapid changes in the temperature of the atmosphere 
surrounding the infant. 

Incubators. — The most efficient incubators are made of metal or 
are porcelain-lined, are simple in construction, and allow of thorough 
ventilation while maintaining the desired temperature. Infections 
being common, the incubator should be so constructed that it can be 
easily cleaned and subjected to sterilization before use. Wooden 

S5 



86 



DISEASES OF THE NEWBORN INFANT. 



incubators are therefore useless. Of the elaborate incubators, that 
of Lion (Fig. 23) has shown the greatest number of successes. 
This incubator can be well ventilated and equably heated. The 
heat is supplied by radiation. The cheaper forms of incubator are 



Fig. 23. 




Lion incubator. 



constructed on the model of that used at the Sloane Maternity, 
New York (Figs. 24 and 25). 

In an emergency any kind of tin-lined box supplied with warm- 
ing bottles, and so protected on top as not to admit of a too rapid 
escape of the air within, answers the purpose of a more elaborate 
apparatus. 






PREMATURE INFANTS. 



87 



The indications for the employment of any form of incubator are : 
(a) Prematurity, the infant weighing 2000 grammes or less. On 
the other hand, infants weighing 1800 grammes can sometimes if 
strong be reared without an incubator. (6) Subnormal rectal tem- 
perature, (c) Cyanosis or sclerema. 

The temperature of the interior of the incubator is regulated by 
that of the infant. If that of the infant is 86° to 89.6° F. (30° to 
32° C), that of the incubator should be 95° to 98.6° F. (35° to 
37° C). 

The infant in any incubator should increase regularly in weight 
and strength ; it should have two movements daily, and take its 

Fig. 24 




Simple form of baby incubator. 



nourishment at regular intervals. If it loses in weight, remains 
cold, cannot be roused, breathes superficially, develops cyanosis, 
dyspnoea, diarrhoea, cough, or vomiting, the outlook is grave. Even 
if the infant is thriving, it should not be allowed to remain tor- 
pid. If the respiratory movements are shallow, the infant should 
be taken cautiously out of the incubator and from time to time 
caused to cry. In this way the lungs will expand and become 
aerated. The infant should be turned on its side and kept lying 



88 



DISEASES OE THE NEWBORN INFANT. 



in that position. In this way hypostasis in the lower and posterior 
part of the lungs is avoided. 

The feeding of the premature infant is a difficult problem. If 
the infant is very young it may not be able to grasp the breast. It 
must then be fed with a pipette or a nursing tube constructed for the 
purpose (Fig. 26). In such cases the milk is pumped from the breast 
and transferred to the infant. If fed with cows' milk, the dilutions 
should contain a low percentage of proteids (0.5 per cent.) and fat (1 
to 1.5 per cent.). The quantity to be given at each feeding should 



AIR VENT 
THERMOMETER 



Fig. 25. 

-THERMOMETER 



N D O W 




C 

A. B. C. 

REMOVABLE 
SECTIONS. 



Plan of simple form of incubator. A, B, water tank heated by lamp ; in this tank are 
the fresh-air pipes. The air is heated before passing into the top section in which the 
infant lives. 



not at first exceed a half ounce, and should gradually be increased 
until the infant arrives at the term age. 

The prognosis varies with the period of prematurity of the 
infant. At the sixth month about 30 per cent., at the seventh 
month 63.7 per cent., at the eighth month 85 per cent., and at eight 
and a half months 90 per cent, are saved (Bertin). These figures, 
of course, are only approximate, and will vary largely with the care 
taken with the incubator and the absence of accidental infections. 
For this reason it has been proposed by Bosi, Giudi, Escherich, 
and others, to construct incubator wards, in which the infant shall 
not be exposed to changes of temperature and to danger of infection 
when taken out of its cradle. 

The most frequent cause of death is infectious bronchopneu- 



ASPHYXIA OF THE NEWBORN INFANT. 



89 



Fig. 26. 




raonia. In such cases percussion rarely establishes dulness of an} 
extent, the respiratory sounds are feeble, air scarcely 
enters the lung, cyanosis is present, and the temper- 
ature may be even subnormal. There may be erup- 
tions on the skin, and death may take place with par- 
tial or general convulsions. 

Morbid Anatomy. — Post mortem are found areas 
of bronchopneumonia with atelectasis. On the sur- 
face of the lungs are hemorrhagic areas resembling 
infarctions. There is hemorrhagic pneumonia. The 
bronchial nodes may be enlarged, and there may be 
pericarditis. The intestines, liver, and kidney pres- 
ent lesions similar to those found in sepsis. The 
hemorrhagic pneumonia is due to infection by strep- 
tococci, staphylococci, Bacillus coli communis, and 
pneumococci (Mussy, Labi, and Levi). These infec- 
tions may be local and limited to the lung, or gen- 
eral. The sources of infection must be sought in 
lesions of the skin, mucous membrane, and respira- 
tory passages transmitting noxious elements from the 
air, dust, or objects brought in contact with the in- 
fant's hands, linen, and food. The prophylaxis is 
therefore clearly indicated. The skin must be kept 
clean and the mouth protected from traumatism and 
infections. The food, preferably the breast, must be 
unirritating. The hands of the nurse must be 
scrupulously clean, and the contents of the diapers 
removed carefully and quickly. 



Breed's feeding 
tube for prema- 
ture infants. 



ASPHYXIA OF THE NEWBORN INFANT. 

Asphyxia is a condition produced by interference with the oxy- 
genation of the blood. In the uterus respiration is effected through 
the placenta. As soon as the placenta is separated in part or as a 
whole from its uterine attachments the disturbance in the circulation 
causes efforts at respiration as a result of dyspnoea, If the placenta 
is separated prematurely, there are consequent efforts at respiration, 
during which liquor amnii and mucus may be aspirated and asphyxia 
thus produced. 

In the extra-uterine form of asphyxia the infant is born and 
makes efforts at respiration, but inherent constitutional weakness, 
weakness of the respiratory muscles, or deformity or disease of the 
lung render full expansion of the lung impossible. 

Morbid Anatomy. — The blood in infants who have died asphyxi- 
ated is thin and fluid. The right heart and large vessels are filled 
with blood, as are also the sinuses of the dura mater, pia mater, and 



90 DISEASES OF THE NEWBORN INFANT. 

liver. The liver is dark and bluish in tint. Punctate hemorrhages 
are found in the pia, pleura, pericardium, peritoneum, liver, kidney, 
retroperitoneal connective tissue, uterus, kidneys, suprarenal capsule, 
and retina. There is a serosanguinolent effusion in the cavity of 
the peritoneum, pleura, and pericardium. (Edema of the extremities, 
scrotum, and connective tissue about the umbilical vessels and pia 
mater, is present. The lungs are dark red and heavy. Ecchymoses 
are seen underneath the pleura and pericardium. In the lungs are 
islands of aerated tissue ; also areas of atelectasis, even though the 
infant has breathed. Trachea and bronchi may be filled with liquor 
amnii, mucus, or meconium. These may be found also in the 
smallest bronchi. The stomach may be filled with air or meconium. 

Symptoms. — If in a normal state when born, the infant breathes 
energetically, cries lustily, and opens its eyes, and the skin, which is 
of a purple hue at first, rapidly assumes a pinkish tint. If asphyxia 
be present, however, we may have two sets of symptoms, which are 
characteristic of two forms of this condition. 

In the first form, or early stage, of asphyxia, the skin has a 
bluish or pinkish-blue tint. The face is swollen and the conjunctivas 
injected. The infant does not move the extremities. The muscu- 
lature retains its tonicity ; the heart is slow but forcible ; the apex- 
beat is apparent to the eye ; the vessels of the cord are filled with 
blood and pulsate ; the respiratory efforts may be shallow and infre- 
quent, or absent ; the infant can be roused and caused to cry. 

In the more advanced form of asphyxia the face is pale and 
w T axy, the lips cyanosed ; the extremities hang lax, and the muscle- 
tonus is absent ; the head falls to one side and the jaw drops. There 
is no attempt at respiration or only imperfect gasping efforts. The 
infant has a corpse-like appearance. The heart-beat is weak though 
palpable. The vessels of the cord are collapsed and pulsation is 
weak. If a few gasps of respiration are made at birth, these soon 
cease. On attempt at respiration the ribs are retracted, but the 
muscles of the face are immobile. Air is prevented from entering 
the lung by the inspired mucus. Reflex reaction is absent ; there is 
no response to irritation. If untreated, infants in this stage of 
asphyxia die. If they live, efforts at respiration must be encouraged, 
else the infants relapse into a stupid condition and the respirations 
become superficial. 

Diagnosis. — Asphyxia must be differentiated from the effects 
of pressure due to cerebral hemorrhage occurring at birth in the 
course of prolonged labor or application of the forceps. In a large 
hemorrhage death is rapid, but in slight hemorrhage it may be diffi- 
cult to make a differential diagnosis. If there is a hemorrhage on the 
surface of the brain, the symptoms may closely resemble those of 
asphyxia. The breathing is very superficial ; the infant lapses into 
sopor ; the pulse may at first be slow and subsequently rapid. There 






ASPHYXIA OF THE NEWBORN INFANT. 91 

maybe occasional convulsions. Only the subsequent history will 
clear up these cases. Asphyxia may be combined with cerebral 
hemorrhage. The history of the birth as to the use of forceps and 
the duration of the labor will aid us. If after irritation the infant 
relapses into sopor, if the pulse continues slow and there are repeated 
convulsions, we may assume hemorrhage. 

The prognosis in all forms of asphyxia if untreated is grave, 
and in the second stage is necessarily fatal. If treated, however, 
the majority of these cases recover, especially those in the first stage. 
As to the cases of the second stage, much will depend on the dura- 
tion of the second stage of labor and the compression of the cord. 
The cases in which cerebral hemorrhage of any severity is combined 
with the asphyxia are grave. Little and Mitchell have demonstrated 
that idiocy may subsequently develop in these cases. 

The treatment of asphyxia is directed to clearing the air-pas- 
sages as much as possible of obstructing mucus, increasing the num- 
ber of respirations, and stimulating the circulation. The mucus and 
aspirated meconium are immediately removed from the mouth by 
introducing the finger quickly but gently. If rales are heard in the 
chest, a soft-rubber catheter is introduced as far dow T n as the superior 
opening of the glottis, and as much mucus as possible is removed by 
mouth suction. Introduction of the catheter into the trachea is 
hardly necessary. Special instruments are not always at hand, and 
the catheter is equal to all emergencies. 

In order to stimulate the surface, the infant is quickly placed in 
a bath at 105° F. (40.5° C), and then in a cold bath, thence trans- 
ferred to a warm blanket and rubbed thoroughly dry. After this the 
infant is, if possible, roused by striking the buttocks quite sharply. 
If these methods do not cause the infant to cry and breathe deeply, 
artificial respiration by the Schultze method should be resorted to. 
This method is so well described in all obstetric treatises that 
it needs only brief mention. The operator, standing with his 
body well balanced, grasps the infant by the shoulders, the thumbs 
being on the anterior aspect of the thorax, the index fingers in 
the axillae, and the other fingers on the back of the chest. The head 
is supported by the ulnar side of the wrists. The operator allows 
the infant to hang from his hands down between his legs. The 
infant is then raised or swung upward above the level of the ope- 
rator's head to the vertical, so that the lower part of the trunk of 
the infant is bent on the thorax. The thorax is thus com- 
pressed, causing passive expiration. The infant is held for an 
instant in this position, and then swung down to the original hang- 
ing position. Passive inspiration is thus performed. This manoeuvre 
is repeated about sixteen to eighteen times a minute. During the 
manoeuvres the bronchi and mouth are freed from mucus, meconium, 
and liquor amni, if present. The Laborde method is that by which 



92 DISEASES OF THE NEWBORN INFANT. 

traction on the tongue is made ten or twelve times a minute. The 
Dew method seeks to accomplish the same result as the Schultze 
method by simpler means. The infant is grasped by one hand at 
the nape of the neck, and by the other hand at the knees. The 
thighs rest in the palm of the hand. The thorax is flexed on the 
abdomen, and then extension is performed. Alternate expiration 
and inspiration take place. Inflation of the lungs by means of in- 
struments introduced into the larynx is dangerous. There are other 
methods of artificial respiration which may be resorted to, such as 
the Marshall-Hall method, but, on the whole, the method of Schultze 
seems the most effective. The danger in all cases is in abandoning 
efforts at resuscitation too early. So long as the heart is beating we 
should continue our efforts. After the infant has been brought out 
of the stage of severe asphyxia there is always danger of relapse 
into a soporous state. In this condition flaggellation on the but- 
tocks at regular intervals may be necessary for days at a time. 
After being worked over for days, such infants may die and show 
extensive atelectasis in spite of the fact that respiration has occurred. 



ASPHYXIA SUBSEQUENT TO BIRTH. 

In these cases there is no disturbance of the placental circulation 
previous to the birth of the infant, and therefore no asphyxia. 
Asphyxia appears after birth as a result of some abnormality in the 
respiratory apparatus, or of disease of the lung, such as syphilitic 
hepatization ; of pleural exudate ; of compression of the air-passages 
by a struma ; or of defects of the diaphragm, or deficient develop- 
ment of the lungs. In some cases there may have been injury or 
compression in the vicinity of the respiratory centre. 

Prematurity of the infant carries with it a soft condition of the 
ribs and weakness of the respiratory muscles, an insufficient develop- 
ment of the respiratory centre, and foetal atelectasis, which give 
rise to a state of asphyxia. The more premature the infant the 
more pronounced are these conditions. 

Symptoms. — A premature infant makes no decided effort at 
respiration after birth. Inspiration is absent or is hardly notice- 
able and shallow. Rales are absent. The vessels in the umbil- 
ical cord are filled with blood and pulsate distinctly. The heart 
lias a normal frequency at first ; then the contractions become 
slower and may eventually be increased in frequency. The skin is 
bluish-red in color ; the extremities cool. If there is any disease 
or deformity of the lung, the infant dies soon after birth. These 
cases are only of scientific interest. Of more importance to the 
physician is the premature infant normal in all respects save in the 
fact of its expulsion from the uterus before term. 



ATELECTASIS OF THE LUNG. 93 

Premature infants at the sixth, seventh, or eighth month are not 
all born debilitated, nor are all debilitated infants necessarily prema- 
ture. There are infants born at the eighth month which are as easily 
reared as an infant at full term. 

ATELECTASIS OF THE LUNG. 

This condition has been referred to in the sections on Asphyxia. 
Atelectasis, or collapse of the lung, may be congenital or acquired. 
In the congenital variety the infant is either weakly or born prema- 
turely. The respiratory muscles do not possess sufficient tonus to 
inflate the lung. The result is that the lung remains in the col- 
lapsed foetal state. In the acquired form, the result of obstruction 
of the bronchi or alveoli, compression of the lung by an exudate 
in the pleura, deformity of the vertebral column, or aneurism of 
the aorta, the lung cannot expand. The king at birth is compact, 
the alveoli being collapsed. The respiratory efforts inflate the 
alveoli. In atelectasis the alveoli can be inflated post mortem. 
Any inflammation of the smaller bronchi subsequent to birth may 
prevent inflation of the alveoli, and thus cause atelectasis. Any 
atelectatic area may become inflamed (bronchopneumonia), and sub- 
sequently involve other alveoli. Therefore, in the same lung areas of 
atelectasis and bronchopneumonia may be present, though distinct 
from each other and not necessarily in causal relationship. In such 
lungs atelectatic areas are seen interspersed with inflated areas. The 
collapsed areas are depressed beneath the surface, are of a dark-red 
or bluish color, and are beefy on section. 

The symptoms of atelectasis are not always clearly defined. 
As a rule, the infants if premature are weak ; their torpid state has 
been described in the section on Asphyxia. On the other hand, 
should atelectasis develop some time after birth as a result of inflam- 
mation and plugging of the smaller bronchi, we shall have the 
combined physical signs of atelectasis, bronchitis, and possibly 
bronchopneumonia. In this last class of cases the physical signs 
are as follows : 

Inspection. — There is intense dyspnoea ; the lower ribs are re- 
tracted, and the efforts at inspiration are labored and move the upper 
part of the thorax less than the lower portion. The surface is pale 
and sometimes cyanosed. Efforts at coughing are ineffectual, and 
may bring up a frothy, clear expectoration which adheres to the 
lips. Sometimes the breathing is quite irregular and catchy, or very 
shallow ; at times the infant seems to cease breathing. 

Palpation with the palms of the hands is negative except where 
rales are abundant, when a fine fremitus is present. There is little 
or no vocal fremitus ; it may be increased, or it may be diminished, 
especially in areas designated vesiculo-tvinpanitic. 



94 DISEASES OF THE NEWBORN INFANT. 

Percussion reveals distinct small areas of dulness with a tympa- 
nitic note, slight dulness, or marked dulness, especially if areas of 
collapse are present with pneumonia. Sometimes the note over the 
rest of the thorax, behind especially, is vesiculotympanitic. At 
times when the areas of collapse are small no dulness is elicited. 

Auscultation. — In areas generally situated at the apex or toward 
the base of the lung the air does not seem to enter freely on inspira- 
tion, and the expiratory sound is hardly audible (collapse of area) 
or absent. Breathing is otherwise puerile or exaggerated, rarely 
bronchial. 

In various parts of the lung are heard very fine subcrepitant 
rales. Crepitant rales are very distinctly heard in other areas, and 
are distinguished from the coarser subcrepitant rales by their fine 
quality. Areas of pneumonia can thus be recognized by the fine 
crepitations, by the atelectasis, and by the absence of respiratory 
sounds and dulness. Voice sounds vary greatly. When the infant 
cries the vocal resonance may seem increased, and again normal ; 
or if the pneumonic area is extensive and is in the vicinity of a 
large bronchus, we may have tubular resonance. 

Temperature is often normal or subnormal ; later, it may be 
elevated. 

Convulsions are common in atelectasis — in fact, they are peculiar 
to the disease. They are repeated at frequent intervals, and an 
infant may have three or four attacks of general convulsions in the 
course of the twenty-four hours. At the onset of the convulsions 
the cyanosis increases. 

The diagnosis of post-natal (acquired) lobular atelectasis will 
depend upon : 

Convulsions. — Given the case of a newborn infant delivered 
without forceps or force, in the absence of signs of any other disease 
the presence of repeated convulsions, with cyanosis and dyspnoea in 
the intervals, should make us consider the possibility of atelectasis. 

The presence of areas of slight dulness, or tympanitic dulness, or 
vesiculo-tympanitic resonance all over the chest. 

Fine subcrepitant rales. 

Still finer crepitant rales. 

Areas in which the air enters incompletely. 

Treatment. — The treatment must be directed toward stimulating 
the heart and increasing the respiratory efforts if the infant is weak 
or premature. If the heart is weak, the treatment is much the same 
as in bronchopneumonia. If the infant does not breathe satisfactorily, 
it is well to make it cry vigorously several times in the twenty-four 
hours, so that the callapsed area of lung may be inflated and the mucus 
in the bronchi expelled. Unless made to cry, these infants lie torpid 
and hardly seem to breathe. The areas of atelectasis are thus 
increased. If the temperature is subnormal and the infant seems 



SEPTIC INFECTION OF THE NEWBORN INFANT. 95 

chilled, we may stimulate it by the application of heat externally, 
either by means of warm baths, hot-water bottles, or an incubator. 



SEPTIC INFECTION OF THE NEWBORN INFANT. 

By septic infections are meant certain general phenomena pro- 
duced by bacterial toxins or tox album ins, or by the entry of bacteria 
themselves into the body by way of the blood-channels or lymph- 
atics. The newborn infant is particularly susceptible to infection. 
At this period of life the natural means of defence are lacking. The 
lymph-nodes and spleen are undeveloped, and as a result phagocy- 
tosis, the chief protection of the adult, is absent. The skin also is 
in a very vulnerable state. It is a ready means of entrance for 
bacteria, as are also the mucous membranes (Epstein). The lack 
of febrile reaction also demonstrates the fact that in the newborn 
there is little resistance against invasion of bacteria. With our 
present incomplete knowledge, Ave class as septic infections such 
conditions as diarrhoeas, bronchitis, pneumonia, hemorrhagic condi- 
tions, Winckel's and Buhl's disease, and dermatitis exfoliativa. 

Etiology. — The most frequent causes of septic infection are the 
pyogenic bacteria, the streptococci and staphylococci. Following 
these in order of importance are the bacilli of the coli group, the 
pneumococci, bacilli of general hemorrhagic infection (Babes), the 
Bacillus pyocyaneus (Neumann), the capsule bacillus of Dungern, the 
Bacillus enteritidis (Gartner), found in hemorrhagic affections resem- 
bling Winckel's disease, and the bacillus of Finkelstein, found also 
in a hemorrhagic condition. The bacteria exist in the air of hos- 
pital wards (Emmerich, Babes, Gartner, Prudden). They are found 
in the normal breast milk (Neumann) and in the milk of breasts 
which are the seat of ulceration, fissure, or abscess. The body of 
the mother, the lochia, and also the liquor amnii after rupture of the 
membranes, are all sources whence bacteria may gain access to the 
newborn infant. As a rare source of infection may be mentioned 
the incubator in which septic cases have been nursed (Allard). The 
bath water has been the means of spreading epidemically in institu- 
tions dermatitis exfoliativa (Fischl) and Winckel's disease (Winckel). 

The newborn infant possesses in its own body sources of infection. 
Thus it may infect itself (auto-infection) through the secretions of its 
respiratory passages and through the stump of the umbilical cord, in 
which even in the healthy infant pathogenic bacteria may be found. 

Bacteria or their toxins may gain access to the body through the 
intact or wounded skin, the umbilicus, the mucous membranes (buc- 
cal or pharyngeal), through the lungs in the respired air, through the 
digestive tract by means of the food, through the conjunctivae and 
the ears, and finally through the genital tract. 



9(3 DISEASES OF THE NEWBORN INFANT. . 

Symptoms. — It is almost impossible to particularize any forms 
of sepsis so far as the general symptoms are concerned. The reaction 
in the newborn infant is so imperfect and the signs are so equivocal, 
that it is often only at the autopsy table that the nature of the lesion 
is determined. It will be convenient, therefore, simply to enu- 
merate the objective changes noted in the various structures of the 
body in this disease. 

The skin may be dry, or the seat of localized oedema or sclerema. 
It may be the seat of erythema of a polymorphous variety, either 
on the body or on the extensor surface of the arms or hands. There 
is sometimes a general or localized cyanosis. A peculiar form of 
this cyanosis has been described by Finkel stein — the so-called angio- 
spastic cyanosis — in which a central pallor and peripheral lividity 
are present in the patches. The cyanosis may be limited to the 
hands and feet. 

Eruptions of a pemphigoid character are sometimes seen in 
sepsis of the newborn infant. The vesicles may be the seat of sup- 
puration, or there may be ulcers and intertrigo varying from super- 
ficial erosions to extensive areas of gangrene. The skin may be 
pale or icteric in hue. There are erysipelatous patches, furuncles, 
and abscesses of a multiple variety. 

The mucous membrane of the mouth is dry and fissured, and 
the tongue dry and coated. The roof of the mouth is the seat of ulcer- 
ations, superficial or deep, occurring at the median raphe, where we 
find normally Epstein's pearls, or laterally over the hamular processes 
of the palate bone (Bednar's aphthae). The mouth may be the seat 
of pseudomembranous deposit not due to the diphtheria bacillus 
(Epstein). In these cases of sepsis sprue may engraft itself on the 
mucous membrane of the mouth and extend to the pharynx, oesoph- 
agus, and stomach. The vagina in female infants may be the seat 
of catarrhal or pseudomembranous inflammation. 

Umbilicus. — Normally, pathogenic bacteria are found about the 
stump of the desiccating cord. In septic conditions the cord does 
not fall off promptly. The tissues about the umbilicus are inflamed 
and the seat of phlegmon and suppuration. I have seen pus burrow 
downward toward the bladder along the course of the foetal struct- 
ures. The bloodvessels of the cord may be the seat of inflammation, 
as will be shown later. In some forms of sepsis in which the infec- 
tious material may have gained entrance through the umbilicus, the 
latter may show absolutely no change from the normal. 

Joints. — There may be swelling in the muscles about the joints, 
as in forms of intramuscular abscess, or the joint itself may be the 
seat of septic suppuration or so-called osteomyelitis (Plate V.). The 
shaft of the bone or the epiphysis only may be involved. One or 
many joints may be the scat of suppuration. 

Nervous System. — Functional symptoms, such as apathy, rest- 






PLATE V. 






m* 



'//// 



Sepsis in the Newborn Infant. Suppuration of the 
right knee-joint. Osteomyelitis of the epiphyses of the 
bones forming the joint. 



SEPTIC INFECTION OF THE NEWBORN INFANT 97 

lessness, or convulsions, may be present, or there may be localized 
facial paralysis or paralysis of the extremities, traceable to menin- 
gitis or encephalitis. Hemorrhages in forms of sepsis may give rise 
to paresis simulating the traumatic palsies of the newborn. 

Respiratory Tract. — The respiratory tract may present catarrhal 
or pseudomembranous inflammation of the nose, tonsils, larynx, or 
trachea. The bronchitis and pneumonia, especially in the septic 
forms of diarrhoea, may be of obscure nature and run an insidious 
course. 

The heart may be the seat of septic endopericarditis. This form 
of pericarditis is rarely diagnosed. 

The digestive tract is the seat of septic diarrhoea. In the cases 
described by Fischl and Czerny there was complicating bronchopneu- 
monia of a septic type. 

Hie liver may be the seat of enlargement in cases of extended 
duration, but the spleen is rarely so. ' 

The urine in most cases indicates the presence of a diffuse 
nephritis. 

The body weight diminishes markedly and rapidly. 

The temperature is not characteristic. In the severest forms of 
sepsis it may be normal or subnormal ; in other cases there may be 
a rise of a degree or more. I have seen this in milder cases. A 
new complication may be ushered in with a rise of temperature, 
as often happens with older infants and children, but is not neces- 
sarily so. 

Morbid Anatomy. — Lack of space forbids entering into the 
details of the pathological alterations found in the septic infections 
of the newborn infant. The changes in the skin have already been 
described. Those of the umbilicus will be found under the section 
on Umbilical Infection. The appearances in the mouth, nose, and 
throat have been described, as well as those of the lungs. The 
alterations in the gastro-enteric tract are detailed in the chapter on 
Diseases of the Gastro-enteric Tract. 

The liver and kidneys are the seat of parenchymatous or diffuse 
suppurative changes. The peritoneum is ordinarily intact, although 
formerly authors believed it to be frequently involved. The peri- 
cardium, endocardium, and myocardium may be the seat of slight 
or marked change.-. Microscopical examination of the blood may 
reveal the infecting bacteria. 

Diagnosis. — The origin of some cases of sepsis of the newborn 
infant is so obscure that not only is a diagnosis made with difficulty, 
but it is not always possible to determine the point of entrance of the 
infectious agent. In crypt ogenetic cases no lesion may be visible. 
If an infant cries when diapered or when it is washed in the bath, 
the joints should be examined for suppuration. A pseudomem- 
branous deposit or an ulceration in the mouth is a sign of traumatism 

7 



98 DISEASES OF THE NEWBORN INFANT. 

with infection. A diarrhoea in the newborn infant is of serious 
moment. The umbilicus, if swollen or red, should receive due con- 
sideration. In cases in which there is no external lesion a blood- 
culture should be made to determine the presence or absence of 
micro-organisms in the blood. Puncture of the spleen for the detec- 
tion of micro-organisms has been advised. Such a procedure may 
or may not be advisable, according to the indications present in the 
case. 

Course and Prognosis. — Some forms of acute sepsis prove fatal 
in a few hours. Others, and they are the most common, last from 
a few days to a week. Finally, the subacute cases, w T hich are com- 
plicated with progressive emaciation, diarrhoea, and pneumonia, 
extend over two or more weeks. Septic osteomyelitis and chronic 
omphalitis are especially protracted. The prognosis in these cases 
is always grave. Mild forms of intestinal sepsis, after pursuing a 
short course with fluctuating temperature, may recover completely. 

Treatment. — There is no specific for sepsis in the newborn 
infant. Prophylaxis is of the utmost importance. The hands of 
the accoucheur must be as clean in handling the newborn infant as 
in the treatment of the mother. The cord is tied with precautions 
described elsewhere. The mouth is not washed. As Epstein has 
pointed out, Bednar's aphthae and pseudomembranous inflamma- 
tions are thus avoided. The nasal passages are not inspected more 
than is absolutely necessary. The bath water should be clean and 
not below 100°>. (38° C.). The food should receive attention. 
The infant should not nurse a fissured or an inflamed breast. The 
breast nipple should be cleaned before and after nursing, as stated in 
the section on Hygiene. The room in which the child sleeps should 
be ventilated. Contact with the secretions of the mother (lochia) 
should be avoided. 

Therapeutic measures are directed to combating the symptoms. 
The strength should be supported, and for this purpose alcohol may 
be used with small doses of strychnine. The antistreptococcic sera 
are of doubtful efficacy. The administration of alkalies, such as 
the salicylate, benzoate, and carbonate of sodium, has been strongly 
advocated. High saline enemata are advised by Sahli. 

DISEASES OF THE UMBILICUS. 

The umbilical cord dries up and drops off in five days, leaving a 
granulating stump. In the case of weakly infants the cord may not 
fall off until much later. The stump may become inflamed, and pus 
may form. This in the majority of cases is due to infection. Infec- 
tion usually takes place at the time of ligation or before the cord 
separates from the stump. Gangrene is indicative of infection. 
The appearance of the stump in omphalitis varies. In some cases 






UMBILICAL FUNGUS. 99 

the inflammation is slight, but in others the tissues are red, infil- 
trated, and coated with necrotic masses resembling pseudomembrane. 
Numerous small abscesses may be present. The great danger is 
that the process may involve the umbilical vessels. If the inflam- 
mation remains local, recovery is the rule. If the vessels become 
involved, sepsis may result. 

Therapy. — Proper ligation and care in dressing of the cord will 
in most cases prevent subsequent infection. Cleanliness is of the first 
importance. The hands, instruments, and tape used for ligation 
should be scrupulously clean. The best dressing for the cord is 
sterilized absorbent gauze several layers thick, and perforated in the 
centre. The cord is passed through this perforation and enclosed 
in the gauze. This dressing is renewed daily after the bath. The 
bath water must be clean, and in drying the infant care should be 
taken not to displace the cord. If a suppurating surface appears, 
it should be treated on general surgical principles. As a rule, oint- 
ments should be avoided. The ordinary sterilized wet dressing is- 
sufficient. 

Umbilical Fungus. 

(Granuloma.) 

In some cases the stump does not heal after the cord has sepa- 
rated, and a granulating surface which presents a fungoid appearance 
remains. The grauulating mass may become as large as a beau 
and be pedunculated. There is secretion of pus. The affection 
is a benign one, and should not be confounded with the so-called 
enteratomata, which are rare. The latter are composed of smooth 
muscular fibre and tubular glands. These umbilical tumors have 
been described by Kolaczek, who believes that they are formed by 
prolapsus of a persistent omphalomesenteric duct. Von Heukelom 
asserts that they are intestinal protrusions through true diverticula 
of Meckel. Adenoid tumors of the umbilicus have been described 
by Lannelongue and Fremont. Huttenbrenner has reported a poly- 
poid tumor of the umbilicus, which he believed to be the remains 
of the allantois. 

Treatment. — If small and flat, the granulations are touched 
daily with silver nitrate and a dry dressing is applied ; or the granu- 
lations may be carefully scraped off and the stump dressed with 
sterilized gauze after bleeding has ceased. If the growth is large 
and pedunculated, it should be ligated at its base with silk or catgut, 
and a sterile gauze dressing applied. In a day or two the mass sep- 
arates and healing takes place. 

Infection of the Umbilical Vessels ; Arteritis Umbilicalis. 

In this affection the perivascular connective tissue of the cord 
first becomes infiltrated with serum and oedematous ; later the various 
LofC. 



100 DISEASES OF THE NEWBORN INFANT. 

coats of the arteries are affected. Thrombosis results, with disinte- 
gration of the thrombi. The lymph-vessels in the connective tissue 
of the cord cany the infectious material to the various parts of the 
body. 

Morbid Anatomy. — The vessels running from the umbilicus 
appear as thickened discolored cords. The perivascular tissue is 
infiltrated. The process may begin about a centimetre behind the 
umbilicus and extend downward toward the bladder. The umbilical 
stump may be normal in appearance or inflamed. The lumen of 
the arteries contain thrombi. The vessels may be dilated and con- 
tain disintegrated purulent masses. There may be lobar or lobular 
pneumonia, with pleurisy and hemorrhagic infarction of the lung. 
Parenchymatous inflammation of the liver, kidney, and spleen, and 
suppuration of one or several joints (see Osteomyelitis) may be 
observed. Peritouitis may be a complication. 

The bacteria found in most of these cases have been streptococci 
or staphylococci. 

Umbilical arteritis is a wound infection. It is most frequently 
seen in institutions, and is the result of implantation of septic matter 
on the umbilical wound by the hands or instruments, or through 
the bath water or unclean dressings. Cases have occurred coinci- 
dent with the presence of blennorrhoea. 

The symptoms of arteritis umbilicalis are often indefinite and 
give no clue to the cause of the illness. The infants gradually 
emaciate and succumb, the fatal issue supervening quite suddenly. 
The umbilicus may in these cases have been long healed, and show 
no evidence of disease ; in other cases it is inflamed. There is a 
sinus leading downward and backward toward the bladder, and 
from this pus exudes. A tense, cord-like structure, the inflamed 
umbilical vessels, is felt beneath the abdominal wall. Sometimes 
the first intimation of serious disease is seen in the joints. The 
mother may tell the physician that the infant cries when it is 
bathed or dressed. In these cases the knee, ankle, or hip may be 
swollen, tense, and the seat of exudate. A septic osteomyelitis 
of the epiphyses of the joint is present, resulting in a suppurative 
arthritis. As a rule, more than one joint is involved. In other 
cases the symptoms are indefinite ; there is a slight febrile move- 
ment ; the respirations are increased, and there may be a dis- 
turbance of the bowels ; icterus is present. Physical examination 
may reveal a pneumonia or nephritis. In other words, the symp- 
toms are those of sepsis. 

Prognosis. — These cases are generally fatal. A few of the mild 
cases recover. In these, however, it is a question as to whether 
the vessels have been involved or whether there was a true infection 
of a septic nature. The prognosis is especially unfavorable in pre- 
mature infants. 






HEMORRHAGE FROM THE UMBILICUS. 101 

Phlebitis Umbilicalis. 

In this affection, the veins running from the umbilicus to the 
liver are the seat of an inflammatory process similar to that affecting 
the arteries in the affection just described. There is a true phlebitis, 
with pus in the veins, in some cases extending into the liver. The 
branches of the portal vein are involved. In these cases the symp- 
toms resemble those of peritonitis complicated with icterus. The 
respirations are shallow, the abdomen tense, and the thighs are flexed 
on the abdomen. 

Treatment. — It is hardly necessary to remind the student that 
prophylaxis is in all septic affections the mainstay of the physician. 
Once inaugurated, infective processes in newborn infants are pro- 
gressive. In cases of the palpably umbilical type I have advised 
laving open the structures passing from the umbilicus to the bladder, 
curetting the sinus thus formed, and inducing healing from the 
bottom. Recovery has followed in a few exceptional cases. The 
operation should be performed before general infection has occurred. 
Van Arsdale operated on one of these cases for me, and obtained 
an apparent recovery — that is to say, the sinus leading from the 
umbilicus healed and there were no symptoms for weeks after the 
operation. 

Hemorrhage from the Umbilicus. 

( Omphalorrhagia. ) 

Hemorrhage from the umbilicus may occur («) from the vessels 
of the umbilical cord or (6) from the umbilical wound itself (paren- 
chymatous). 

Hemorrhage from the vessels of the cord may occur if the liga- 
ture has not been properly applied ; but faulty ligation alone will 
not in all cases account for the hemorrhage. Runge states that 
if the cord is cut ten or fifteen minutes after a healthy infant has 
cried lustily, there will be little hemorrhage — certainly not one 
threatening life. The diminution of arterial pressure in the blood- 
vessels at this point, due to the establishment of the pulmonic circu- 
lation and the natural contractility of the vessels, will prevent 
hemorrhage. The fact that infants among savage peoples and the 
young of lower animals do not die although the cord is not ligated, 
but simply divided, is thus explained. If an infant, therefore, 
bleeds from an imperfectly applied ligature the reason must be 
-ought in some physiological or anatomical defect of the bloodves- 
Bels. We possess no data to explain the absence of normal arterial 
contraction in the vessels of the cord. Inasmuch as this condition 
may be present during the first days after birth, great care should 
be taken that the ligature is properly placed. Caution should espe- 
cially be exercised with premature infants, in whom the bloodvessels 



102 DISEASES OF THE NEWBORN INFANT. 

are in an embiyonal state. The method of ligating the cord will 
be found detailed in works on obstetrics. 

After the separation of the umbilical stump a few drops of 
blood may be seen on the wound from time to time. This is of no 
moment. The wound should be dressed with a salicylic powder 
and amylnm (1 : 5), and covered with a dry dressing. 

Idiopathic Hemorrhage from the Umbilicus. 

{True Omphalorrhagia.) 

Occurrence. — Winckel, quoted by Kunge, has seen in 5000 
births only 1 case of true idiopathic hemorrhage from the umbilicus. 
Males are more frequently attacked than females. I have seen few 
cases of this affection. 

Etiology. — According to Grandidier, infants apparently healthy 
and strong are for the most part affected. This form of hemor- 
rhage occurs also in infants suffering from congenital syphilis, 
septic affections, or the acute fatty degenerations of the newborn. 
In some forms of congenital syphilis there may be hemorrhages 
into the skin, stomach, intestine, and internal organs. In these 
cases it is not surprising that hemorrhage should also occur from 
the umbilicus. Icterus, due to syphilitic affections of the liver and 
lung, may be present. 

In 51 cases of hemorrhage from the umbilicus, Epstein found 
pronounced septicemia in 24. The affection is especially prevalent 
under unhygienic conditions and in foundling asylums. Klebs, 
Eppinger, Cohnheim, and Weigert have described cases of hemor- 
rhage in which micro-organisms of various kinds were found in the 
blood and in the hemorrhagic areas. Bacterial colonies were found 
in the arterial thrombi and in the lungs and kidneys. 

The occurrence of hemorrhage from the umbilicus in Buhl's 
disease is elsewhere referred to. 

Symptoms. — About the fifth day after birth, immediately follow- 
ing separation of the umbilical stump, blood is seen to ooze from the 
umbilicus. It does not appear to issue from any particular vessel, 
but oozes from the whole wound, as from a sponge. The flow may 
be slight at first and then profuse, or may be profuse from the out- 
set. Pressure upon the wound may cause the hemorrhage to cease, 
but the flow begins when pressure is withdrawn. In some cases the 
infants have enjoyed excellent health previous to the hemorrhage. 
In others there may have been a slight icterus or diarrhoea. How- 
ever this may be, after bleeding commences cyanosis and icterus 
of the general surface appear, giving the skin a peculiarly bronzed 
appearance. There are hemorrhages from the stomach and gut. 
Ecchymoses appear in the vicinity of the umbilicus and on other parts 
of the trunk. (Edema of the ankle-joints and wrists supervenes. 






UMBILICAL HERNIA. 103 

The hemorrhage from the umbilicus is the most characteristic symp- 
tom, and cannot be controlled by any means. The blood coagulates 
very slowly. 

Duration. — The disease lasts from a few hours to two weeks. 
Grandidier's statistics give a mortality of 83 per cent. Death 
ensues in collapse, with coma and convulsions. 

Treatment is directed to controlling the hemorrhage by press- 
ure or bv transfixing the umbilical wound. From a study of the 
pathogeny of this affection, it is evident that no treatment can be 
successful. 

Umbilical Herniae. 

In newly born infants we distinguish two varieties of hernia at 
the umbilicus. 

The first form is of serious character. It is really a hernia of 
the umbilical cord (hernia funiculi umbilicalis). The condition is 
due to an arrest of development, as a result of which there is a true 
defect in the abdominal wall at the situation of the umbilicus. The 
gut prolapses and is covered by the amnion of the cord and Wharton's 
jelly, beneath which is the peritoneum. The latter is immediately 
over the gut. Many of the infants thus affected are premature. 
In others deformities are present. The hernia is a round or oval 
tumor of the size of a walnut or an orange, located in the region 
of the umbilicus, and is continuous with the cord. The sac of the 
hernia is formed by the peritoneum and amnion. The abdominal 
walls form the border of the sac. Gut, liver, spleen, kidney, or 
pancreas may be found in the sac. 

If treatment is not instituted at the time of separation of the 
cord, and the hernia is large, ulceration, gangrene, or septic perito- 
nitis in the sac contents may result. 

The second and most common form of hernia in this region 
is due to a weakness at the point of insertion of the cord. The 
hernia becomes apparent a few weeks after birth, when the cord has 
completely cicatrized. It is then noticed that when the infant cries 
there is a protrusion at this point. The protrusion may be small or 
large, and is covered by the thin cicatrized skin. The hernia may 
be central or at one side, or a little above or below the centre of the 
umbilical ring. 

The treatment of the first form is purely surgical, and consists 
in splitting open the sac and sewing the abdominal parietes in 
apposition. The treatment of the second form is simple. As a 
prophylactic measure a small pad should be placed on the abdomen, 
underneath the binder, and should be worn for some time after 
the stump is healed, in order that there may be no protrusion of the 
wall and gut during crying spells. If the hernia has taken place, 
a firm pad, made by enclosing a piece of thick cardboard, one 



104 DISEASES OF THE NEWBORN INFANT. 

and a half inches in diameter, in a piece of linen, should be 
applied, and supported by rubber plaster. Another method is to 
reduce the heruia, fold it inward by means of the apposing abdominal 
walls, and secure the walls thus brought together with plaster. The 
plaster should be renewed every three days lest ulceration of the 
skin result. As soon as the muscles of the abdomen gain strength 
and the infant is able to stand, the opening at the umbilicus closes 
and the hernia remains reduced. 



MEUENA NEONATORUM. 

This is a disease of the newly born characterized by a discharge 
of blood from the rectum and by vomiting of blood. It is a rare 
affection, occurring about once in 1000 births (Kling, Genrich, 
Kunge). The hemorrhages occur in two distinct conditions : 

(«) As a symptom of a constitutional dyscrasia. This condition 
has been treated of under the headings of Hemorrhagic Congenital 
Syphilis, Sepsis, and the Acute Fatty Degeneration of the Newly Born. 
Runge has shown that not only may these diseases named cause 
melsena, but. also that any of the infectious diseases of the newly 
born may give rise to this condition. 

(6) The second condition in which melsena occurs is that in which, 
as Landau, in his monograph on this disease has shown, local lesions, 
such as erosions and ulcerations resembling ulcus ventriculi, exist 
in the stomach and gut of the newly born infant. Hecker, Spiegel- 
berg, and others have also described these ulcers of the stomach 
which produce the symptoms of mekena. Landau attributes the ulcer 
to embolism resulting from a thrombus of the umbilical vein or the 
ductus Botalli. Embolism in any artery of the mucous membrane 
of the stomach gives rise to necrosis and erosion, with the opening 
up of some arterial branch. Ingenious as this theory is, it is not 
accepted unreservedly by all (Kundrat), although Landau has proved 
the presence of emboli in the vicinity of stomach ulcerations. 
Another theory ascribes the ulcerations to hyperemia of the mucous 
membrane in asphyxia and traumatism. 

In addition there are cases in which no cause for the symptoms 
can be detected. 

Morbid Anatomy. — Post-mortem examination shows the gastro- 
enteric tract to be filled with dark hemorrhagic masses. The 
mucous membrane may be normal, the seat of erosions of greater 
or lesser extent, or there may be hemorrhagic areas scattered 
throughout the gut. These may be confined to the stomach or 
duodenum. There may be true ulcers, measuring J to 2 cm. in 
diameter, resembling those- seen in the adult (Winckel). In some 
cases the thrombosed or eroded vessel is found in the floor of the 



ACUTE FATTY DEGENERATION OF THE NEWBORN INFANT. 105 

ulcer or in its vicinity. All the organs are anaemic, and if syphilis 
or some other general disease exists we have the changes found in 
these conditions. 

Symptoms. — From two to four days after birth it is noticed that 
the infant is somnolent or restless ; there may be hemorrhagic stools 
or vomiting of bloody masses, or both these symptoms may be pres- 
ent at the same time. The principal symptom, however, is the 
bloody stools. These are at first mingled with meconium, and later 
become frequent and profuse. The vomited matter consists of 
mucus streaked with blood, or masses of blood of brownish color. 
The amount of blood lost by the bowel within twenty -four hours 
may be enormous. Under these conditions death ensues within a 
period of from twelve to twenty-four hours, with all the symptoms 
of acute anaemia. In other cases there may be a cessation of the 
intestinal hemorrhage for from twenty-four to forty -eight hours, but 
recovery does not always take place, and sudden death from a severe 
hemorrhage may occur at any time. 

The prognosis is grave. Sixty per cent, of the infants affected 
die. The outlook is more serious in conditions of sepsis, syphilis, 
and acute tatty degeneration than in melsena due to ulcer of the 
stomach or duodenum. 

Diagnosis. — We must differentiate this disease, which is called 
true melama, from the so-called spurious forms, in which the infant 
simply passes blood swallowed with the food. This spurious form 
may occur if the breast nipple is fissured or if there is a fissure of 
the anus. In other cases blood from the nose or mouth of the 
infant may be swallowed. Hemorrhages of this kind may occur as 
part of a general septic infection. In many cases there may be, with 
other hemorrhages, icterus, cyanosis, oedema, pointing to some gen- 
eral disease. Sensitiveness in the region of the stomach points to 
ulceration of this organ. 

Treatment. — The hemorrhages should be controlled by the appli- 
cation of a cold coil to the epigastrium and the administration of cold 
drinks. Henoch recommends a drop of liquor ferri sesquichloridi 
every hour in barley-water. Ergotin is given in doses of J to f 
grain internally or subcutaneously. Enemata are not advisable. 
Heart is stimulated with strychnine, digitalis, camphor, or ether. 

ACUTE FATTY DEGENERATION OF THE NEWBORN 

INFANT. 

(Buhl's Disease.) 

This disease, first described in 1861 by Buhl, is an acute 
parenchymatous fatty degeneration of the liver, kidney, or heart, 
combined with hemorrhages into the various organs, or from the 
umbilicus, intestines, or stomach. 



106 DISEASES OF THE NEWBORN INFANT. 

Etiology. — The disease is found in the lower animals, especially 
in sheep. In the human subject it is probably a form of septic 
infection, although in Buhl's cases the vessels of the umbilicus 
had a normal appearance. Runge believes that with modern histo- 
logical and bacteriological methods an infectious agent will be 
ultimately discovered. Septic infection may occur without any ap- 
preciable changes about the umbilicus or elsewhere on the surface 
of the body (cryptogenetic). The disease is very rare ; many cases 
described as omphalitis and hemorrhage from the umbilicus are 
probably BuhPs disease. 

Morbid Anatomy. — The body is icteric or cyanotic; there is 
oedema of the surface, and not infrequently hemorrhagic areas in the 
skin. The umbilicus may be covered with blood, but the vessels 
and wound are otherwise normal. Hemorrhages or petechias are 
found in most of the internal organs, especially the pleura, pericar- 
dium, mediastinal tissue, muscles, and mucous membranes. The 
heart is the seat of fatty degeneration, as is also the liver which is 
enlarged. The spleen is enlarged and soft. The kidneys are the 
seat of fatty parenchymatous changes. The stomach and intestines 
are filled with blood. There are hemorrhages into the mucous 
membrane of the stomach and intestine. 

Symptoms. — The children are born partially asphyxiated. At- 
tempts to resuscitate them are not fully successful. Some die in 
asphyxia, others after a time have bloody diarrhoeal stools. At 
times there is vomiting of blood, and when the stump of the cord 
separates there is hemorrhage from the umbilicus. The bleeding from 
the umbilicus is parenchymatous, and may be so profuse as to cause 
death. The skin is at first cyanotic, then icteric in hue. Large 
hemorrhagic areas appear in the skin, conjunctivae, and mucous 
membrane of the mouth, and bleeding may occur from the ear and 
nose. Icterus may become extreme. At times oedema of the sur- 
face appears. The temperature is not raised. Death ensues in 
collapse. The external hemorrhages and icterus are absent in some 
cases. 

Diagnosis. — In the newly born infant this symptom-complex is 
unique, and must be looked upon as a form of sepsis either through 
the umbilicus or through some other avenue. In the newly born 
infant this disease may be confounded with death from asphyxia. 
In all cases of medico-legal import the organs should be examined 
for parenchymatous changes before an opinion is given. 

Prognosis is fatal. 

Treatment. — The physician endeavors to bring the infant out 
of the state of asphyxia. It can be easily understood that he stands 
helpless in the face of the parenchymatous hemorrhages and degen- 
erations, for which there is no remedy. 



WISCKEL'S DISEASE. 107 

WINCKEL'S DISEASE. 

(Epidemic Hemoglobinuria of the Newly Born.) 

This disease, first described in the epidemic form by Winckel, is 
characterized by the sudden appearance of cyanosis and icterus with 
hemoglobinuria. 

The etiology of the affection is obscure. The symptomatology 
resembles that of Buhl's disease. Epstein, Strelitz, and Baginsky 
consider the disease a form of septic infection. WinckeFs cases 
were believed to be due to the use of infected drinking or bath 
water. 

Symptoms. — The symptoms in WinckeFs cases appeared on the 
fourth day after birth in apparently healthy and well-developed newly 
born infants. The average duration was thirty-two hours. Some 
infants succumbed in nine hours after the onset of symptoms. Rest- 
lessness and cyanosis were first noted. The latter was general, 
affecting the trunk and extremities. Icterus then developed, and 
became marked within twenty-four hours. The respiration and 
pulse were increased; the temperature was normal (100.5° F., 
38° C.) ; the skin was cool. At times there were vomiting and 
diarrhoea. The urine was passed with tenesmus, was brownish in 
color, and contained blood-cells, haemoglobin, renal epithelium, gran- 
ular casts, micrococci, detritus, and ammonium urate. Convulsions 
closed the scene. If the skin was cut, a brownish syrupy fluid 
escaped. 

Post-mortem examination revealed no disease of the umbilicus 
or umbilical vessels. The kidneys were the seat of cortical hemor- 
rhages. The spleen was large and hard, and filled with pigment. 
There were punctate hemorrhages in almost all the organs, especially 
in the pleura, pericardium, and endocardium. Hemorrhages were 
present in the mucous membrane of the stomach and gut, and under- 
neath the liver capsule. Peyer's patches, solitary follicles, and 
mesenteric glands were enlarged. The liver, heart, and various 
organs showed fatty degeneration. There were bacterial foci in the 
liver and kidneys. The blood showed an increase in the leucocytes 
and in the free granules. 

Diagnosis. — Owing to the similarity of symptoms, WinckeFs 
disease may be confounded with Buhl's disease. The former pursues 
a very malignant course, and does not present the intestinal and 
stomach hemorrhages to the same extent as the latter. 

Runge and others are inclined to believe that all these hemor- 
rhagic aifections are due to a common cause — septic infection. The 
hemoglobinuria is simply a marked hemorrhage into the kidney. 
Parenchymatous fatty degeneration of the various organs is common 
to both affections. 



108 DISEASES OE THE NEWBORN INEANT. 

TETANUS OF THE NEWBORN INFANT. 

(Trismus Neonatorum.) 

Tetanus of the newborn infant is in the majority of cases due to 
infection of the umbilical wound by the tetanus bacillus. The 
bacillus is conveyed to the wound by means of unclean hands, band- 
ages, or filth of any kind. As a result of the growth of the bacillus 
ptomaines (Brieger) are formed, enter the circulation and are widely 
distributed throughout the body. Infection may occur at the time 
of the ligation of the cord, or during the separation of the stump. 
In 8 per cent, of the cases the disease manifests itself immediately 
after birth (Hartigan). As a rule, however, it occurs from the fifth 
to the twelfth day after birth (Runge). It is rare after the third 
week. It is common in districts in which uncleanliness in the. 
methods of treating the umbilical cord prevails. It is endemic in the 
Faroe islands, and is common in the Hebrides, Cuba, and Jamaica. 
Negroes especially are prone to the malady, on account of their lack 
of cleanliness in treating the cord. Tetanus of the newborn infant 
has been demonstrated by Beumer and Peiper to be identical with 
tetanus in the adult. 

Morbid Anatomy. — Beck has described two cases of tetanus 
with swelling of the motor ganglion-cell, and degeneration of the 
peripheral portion of the cell and atrophy. There are also changes 
in the chromatin. Congestion and hemorrhages in the brain and 
cord, serous exudates in the cord, and congestion of the internal 
organs, due to convulsions, are present. 

Symptoms. — There is a premonitory period of restlessness. The 
infants awake abruptly from sleep. They nurse badly, let go of the 
nipple suddenly, and cry. The peculiarity of the disease in infants 
is the predominance of trismus, with which the attack begins. 
The lower jaw becomes rigid and fixed at a distance of a few lines 
from the upper jaw. It is impossible to introduce the nipple between 
the teeth. The forehead is wrinkled, the palpebral fissure dimin- 
ished, and the lips are puckered. At intervals this spasm relaxes. 
The condition of rigid spasm spreads to the muscles of the body, 
and there is opisthotonos. At the outset during the intervals 
between the attacks of rigidity the body is lax ; these intervals 
become shorter and shorter, until finally the body is in a state of 
constant rigidity, resting on the heels and the back of the head. 
Dyspnoea with resultant cyanosis is present when the muscles 
of respiration become affected. Deglutition is impossible. There 
is no cry, on account of spasm of the laryngeal muscles. The tem- 
perature may reach 106° F. (41° C). In protracted cases it may 
be normal. The urine and feces are passed involuntarily. There 
is albumin in the urine. The respirations are superficial. The heart 



OPHTHALMIA NEONATORUM. 109 

action is increased ; the pulse may be 200. During a contracture 
the skin is dark red and cyanotic. Icterus may be present. The 
face is fixed in expression and oedematous. 

Duration. — The disease lasts from a few days to three weeks. 
Death may ensue in from one to six days from asphyxia or exhaus- 
tion. In rare cases the attacks become less and less frequent, and 
finally cease. Fracture of the bones and rupture of the muscles are 
amoug the complications. 

Prognosis. — The prognosis is grave. Baginsky lost all of his 
cases in newborn infants, while Escherich, Soltrnan, and Monti report 
recoveries. Cases which occur late, after separation of the cord, 
give a better prognosis (Papiewski). 

Treatment. — Prophylaxis is of the utmost importance in this, as 
in other diseases of the newborn infant. Cleanliness in handling the 
cord is of the first importance. Escherich cauterizes the stump of the 
cord, to destroy any bacilli of tetanus which may be present. On the 
appearance of trismus, the treatment is first directed to the relief of 
the tonic spasms. Chloral hydrate in grain j (0.06) doses every few 
hours, by mouth (if possible), or by the rectum, is a very useful drug. 
Calabar bean in the form of extract is recommended by Monti, who 
gives yrj-g- grain (0.0005) subcutaneously, repeated until the desired 
eifect is obtained. Cannabis indica, grain i (0.03) every two hours, 
is also given internally. Curare has been used but little with the 
newborn infant. Of the other remedies, bromide of potassium and 
trionol have little eifect. 

The use of the tetanus antitoxins has not given satisfactory results, 
probably owing to the fact that tetanus is a symptom of advanced 
toxaemia of the nervous system. In such a condition the action of 
any antitoxin would be exerted too late to give permanent benefit. 



OPHTHALMIA NEONATORUM. 

Ophthalmia neonatorum is an inflammation of the conjunctiva?, 
of gonorrhoeal origin. The infant may be infected intrapartum or 
after birth. The source of the infection may be the parturient canal 
of the mother, or the infections agent may be conveyed to the eyes 
by the finger of the accoucheur. Postpartum the infant may be 
infected by any means which conveys gonococei to the orbital con- 
junctivae. In institutions an infant may be infected by a careless 
nurse's washing the eyes with unclean linen. The period which 
elapses from the time of infection to the onset of symptoms varies 
from two to five days. There is a discharge from the conjunctivae, 
the eyes are congested, the conjunctivae swollen, and the eyelids 
-wollen and chemosed. At first a thin yellow serous discharge 
escapes from between the lids. This soon becomes thick and 



110 DISEASES OF THE NEWBORN INFANT. 

creamy and of a yellowish or icteric hue if icterus is present. The 
lids are so swollen and oedematous that it is scarcely possible to 
separate them. When separated the conjunctiva of the lids pro- 
lapses. The cornea is rough and covered with secretion, and 
shreds of pseudomembrane may adhere to the palpebral conjunctiva. 
If not controlled, the inflammation progresses until the whole depth 
of the cornea is involved and perforation occurs, with prolapse of 
the iris, escape of the humor, and panophthalmitis. 

The duration of the disease varies ; as a rule, it lasts from three 
to five weeks. 

This gonorrhoea! form of ophthalmia must not be confounded 
with a much milder form of conjunctivitis which is also seen in the 
newly born infant. In these cases, also, the infant is infected by 
the mother or nurse, but the inflammation is of a benign nature, 
and is not clue to the gonococcus of Neisser. In this form of oph- 
thalmia the diplococci and streptococci of the vagina of the mother 
are the etiological factors. The swelling of the lids is not marked, 
the symptoms are mild, and the course favorable. 

Prognosis. — The prognosis of gonorrhoeal ophthalmia depends 
on an early diagnosis, the degree of the severity of the infection, and 
timely treatment. It is grave in all cases. 

Treatment. — The advice of an ophthalmic surgeon should be 
sought as soon as symptoms are manifest. As a prophylactic 
measure, immediately after birth a drop of a 2 per cent, solution of 
silver nitrate should be instilled into the eyes. The immediate 
result is a cloudiness of the cornea, due to the formation of albu- 
minate of silver. The cloudiness disappears in a few days. If only 
one eye is aifected, the healthy eye should be carefully bandaged, so 
that infection cannot reach it. The infant should be placed in the 
hands of a special nurse, and pieces of lint, two inches square, should 
be kept on ice and applied to the lids every ten minutes. The 
secretion should be washed away as soon as formed, with a 1 : 500 
boric acid solution applied with a dropper. Some surgeons wash 
the eyelids and conjunctivae daily with a 1 to 3 per cent, solution 
of silver nitrate. The infant and nurse should be isolated, and all 
dressings burned as soon as soiled. 



ICTERUS IN THE NEWBORN INFANT. 

The majority of newly born infants are icteric. Icterus in the 
otherwise normal newly born infant should be differentiated from 
that due to sepsis, syphilis of the liver, cirrhosis of the liver, steno- 
sis of the common bile-duct, and yellow atrophy of the liver. Acute 
yellow atrophy of the liver in the mother during pregnancy may 
produce an icteric condition in the newborn infant. 






ICTERUS NEONATORUM. Ill 



Icterus Neonatorum. 



Opportunity to inspect post mortem the viscera of cases of icterus 
neonatorum is rarely afforded, since recovery ensues in the majority 
of cases. In cases which have come to the autopsy table, all the 
internal organs, including the bones and cartilages, were icteric. The 
spleen and kidneys were but little affected, even in severe forms, 
bv the general icteric discoloration. The liver was macroscopically 
rarely jaundiced. The intima of the arteries, the fluids in the serous 
cavities, the pericardial fluid, and the subcutaneous and intermuscular 
connective tissue have been found to contain bile-pigment and biliary 
acids (Birch-Hirschfeld). The contents of the gut were normal. 
The kidneys contained uric acid infarctions. 

Symptoms. — Fully 80 per cent, of all newly born infants be- 
come jaundiced shortly after birth (Runge). The jaundice appears 
on the second or third day after birth. The icterus may be slight 
and involve only the face, breast, and back, or may be severe and be 
seen over the whole surface. In severe forms icterus of the con- 
junctiva? is present. In this feature icterus neonatorum differs from 
ordinary catarrhal icterus, in which icterus of the conjunctivae is 
the first symptom before the skin is perceptibly tinged. The con- 
junctivae are last to be tinged in the jaundice of the newly born. 
Infants suffering from icterus, though in an apparently normal con- 
dition, do not increase in weight as normal infants do. They may 
even lose ground. AVhen they recover lost weight, they do so slowly. 

The urine is brownish at times and contains biliary pigment and 
acids (Cruse, Hofmeier). 

Etiology. — Icterus neonatorum is as frequent in institutions 
as in private practice. It is more common among boys (Kehrer). 
It is seen in premature weakly infants, and in those whose birth 
has been attended by complications. The disease is now traced 
to both a hematogenous and a hepatogenous source. There are 
certain processes in the blood which also involve the functions 
of the liver. According to Hofmeier and Silbermann, there is a 
disintegration of red blood-cells in the circulation. These disinte- 
grated red blood-cells are converted by the liver cell into biliary pig- 
ment ; the solids of the bile are increased, as is also the gross 
quantity of bile (Minkowski, Xaunyn, Stadelmann). It is not 
known, however, how this increase of bile-pigment gains access to 
the circulation. One theory (Silbermann) is that with the processes 
described above, certain ferments are set free which cause circulatory 
disturbances in the liver. Stasis results in the bloodvessels, with con- 
sequent pressure on the biliary ducts. Resorption of bile thus follows. 

Treatment. — Icterus neonatorum, if untreated, disappears in 
three or four days in mild cases ; severe cases are more protracted. 
Neither form needs special treatment. 



112 DISEASES OE THE NEWBORN INFANT. 

SCLEREMA. 

(Sclerema Neonatorum; Scl er oedema ; Sclerema Adiposum.) 

This peculiar and rare affection is apt to be confounded with 
ordinary oedema. There are two forms of this condition : sclere- 
dema, or edematous sclerema ; sclerema adiposum, or fat sclerema. 

Scleredema. 

Scleredema is an accumulation of fluid in the subcutaneous 
connective tissue, causing the skin to be raised from that tissue. 
The skin resembles marble, and is hard, tense, and glistening. 
The infiltration causes a stiffness of the body, with rigidity of 
the extremities. The swelling begins, as a rule, in the calves of 
the legs, and spreads to the buttocks, thighs, and trunk. The nose, 
cheeks, and lips become hard, and the skin is lardaceons. The 
joints are stiff ; the infant does not nurse, being unable to suckle. 
The surface is cool, and the internal temperature may fall to 
89.6° F. (32° C.) or 71.5° F. (22° C). There is in this form a 
true exudate underneath the skin. In some cases we may have 
ecchymoses in the tense, white, glistening skin. It affects weakly 
newborn infants. 

Sclerema Adiposum, or Fat Sclerema. 

This condition follows or complicates exhausting diseases, and 
is also seen complicating diarrhea or pneumonia. It is generally 
a forerunner of death. The skin becomes hard, but is not lifted 
up by an exudate, and the limbs are immovable. On the contrary, 
the skin is collapsed, and resembles that seen in atrophic states. 
This condition is really a dryness of the tissues. The skin has lost 
its natural resiliency, but does not pit on pressure. The hardening 
begins on the lower extremities, and the inner part of the thighs or 
in the cheeks. It spreads thence. The skin is not tense. The 
external and internal temperatures are reduced. The condition ends 
usually like the first form, fatally. It is not confined to newborn 
infants, but may affect older ones. In these cases also the sclerema 
affects the whole trunk and may spread to the face. The cheeks 
cannot be lifted up in folds. 

Diagnosis. — The diagnosis is not difficult. The condition in 
which the skin is tense and does not pit as in edema is character- 
istic. In the second form the skin feels much like that of a corpse. 
It may even retain its original wrinkled condition if the infant is 
atrophic. With our present imperfect knowledge it is well to keep 
these forms of disease in a class apart from the sclerema with sclero- 
dactylia seen in adults or in older children. 



INJURIES INFLICTED DURING BIRTH. 113 

The etiology of scleroedema or acute oedema is still a matter of 
speculation. Weakness of the heart, the beginning of nephritis, an 
infectious agent of some kind (Baginsky), certain marked deficiencies 
in the respiration and circulation in premature infants, and unhy- 
gienic surroundings, all have been advanced to explain this rare con- 
dition. In the secondary form of sclerema adiposum there is to a. 
certain extent a desiccation of the subcutaneous tissues. Sanger 
thinks that the excess of palmitin and stearin in the subcutaneous 
fat of the newly born infant may account for the peculiar solidifi- 
cation as soon as the temperature is reduced, as it is in sclerema. 
There are cases of sclerema in which the temperature is elevated, as 
in Barker's case, so that the theory of Sanger is scarcely adequate. 
The cases of fat sclerema which I have seen created the impression 
of an infectious condition. Barker found streptococci in the internal 
fluids after death. 

Prognosis. — Most infants having the ©edematous form die. I 
have seen one case of fat sclerema involving the buttocks and inner 
part of the thighs, recover. 

Treatment. — AVith a view to prophylaxis, the utmost cleanliness 
should be observed at birth, and extreme care taken with the cord 
and its dressing. If the temperature is subnormal or the infant 
premature, every effort should be made to supply the requisite 
warmth by artificial means. The nourishment should be carefully 
selected. In the secondary form of sclerema the same general treat- 
ment is pursued. The heart is stimulated and heat is supplied arti- 
ficially. Localized forms are treated with cautious massage of the 
affected areas. 



INJURIES INFLICTED DURING BIRTH. 

Among the injuries incident to birth are those of the face. 
Pressure of the forceps blade may cause facial paralysis. This, as a 
rule, disappears in time, though in severe injury of the nerves it may 
remain permanent. Indentations of the cranial bones may result 
from the pressure of instruments. In these cases the bone is 
depressed, and in the space between the scalp and bone there is an 
effusion. The edge of the bone surrounding the depression is 
distinctly felt. These depressions need no treatment, as they 
di-appear in time. Traction on the arm may cause a so-called 
birth palsy, which is the counterpart of Erb's palsy in later life. 
The paralysis in these eases sometimes remains permanent. Others 
recover. As a rule, one arm is affected, but in rare cases both arms 
may be paralyzed. The symptoms are characteristic. In a few 
days or at a later period after birth it is noticed that the infant does 
not move one or the other arm (Fig. 27). The affected limb hangs 



114 



DISEASES OF THE NEWBORN INFANT. 



loosely and without power of motion. The fingers or hands may- 
be mobile. The affected arm is cold and the hand may be bluish 
in tint. After a time atrophy of the muscles about the shoulder- 
joint may set in. The bony prominences then come into relief. 
If the arm does not recover power, the muscles continue to atrophy, 
and there may be subluxation of the head of the humerus at the 
shoulder-joint. The child in these cases always holds the injured 
arm with the sound one, in order to protect and support it. At the 
early period the reactions of degeneration are present, and if the 
muscles recover, the reaction to the galvanic and faradic current 



Fig. 27. 



KM m 




^S^bBf i 




flf 4 
f 






* 



Birth palsy affecting the left arm, atrophy of the muscles about the shoulder. 

becomes normal. If recovery does not take place, the disappearance 
of galvanic and faradic irritability of muscle goes hand in hand with 
the muscular atrophy. 

The treatment of these obstetrical palsies is similar to that of 
Erb's palsy. The arm is protected from traumatism. Massage is 
performed within two weeks after injury, and after four weeks the 
faradic current is applied to cause muscular contraction. Electricity 
is applied for a short space of time daily. The progress of these 
cases can best be judged under treatment. As a rule, recovery 
takes place in a few weeks. In other cases recovery may be delayed. 
In a third set of cases recovery never takes place. The galvanic 
and faradic contractility disappears from muscle and nerve, and 
permanent atrophy and disability remain. In these cases there is 
also retarded growth of the other tissues, such as bone. 



PLATE VI 










Hsematoma of the Sternomastoid Muscle of the Right Side 
in a Newborn Infant. Swelling at the centre of the anterior 



border of the muscle ; 
torticollis. 



contraction of the muscle with 



CEPHALOH^EMA TOMA. 115 

Hematoma of the Sternomastoid Muscle. 

This affection is the direct result of traumatism during delivery. 
As a rule, it is seen in cases of breech presentation in which trac- 
tion has been exerted on the after-coming head. In the majority 
of the cases coming under my observation the sternomastoid muscle 
of the right side was affected (Plate VI.). The infant holds the 
head on one side. The muscle of the affected side is contracted, 
and the position of the head is that seen in torticollis. A hard 
nodule is felt along the inner border of the sternomastoid muscle, 
about the junction of the lower third and upper two-thirds. The 
tumor is usually the size of a small hazelnut, but may be much 
larger. Manipulation causes pain. The skin over the tumor is 
movable and not discolored. 

The progress of the affection in all of these cases is much the 
same. The tumor becomes smaller as the exudate is absorbed, but 
the torticollis persists, although in time this may disappear. The 
nature of these tumors is probably that of a hematoma caused by 
rupture of muscular fibres and bloodvessels. 

The treatment is simple. At first the tumor should be let 
alone. After a few days gentle massage with the finger moistened 
with oil is permissible. When the growth hardens the massage may 
be more vigorous, and be supplemented with an attempt at each sit- 
ting to turn the head gently to the opposite side and thus stretch 
the contracted muscle. Cases which do not recover must be treated 
by surgical means later in life. 

Cephalhematoma. 

Cephalhematoma is an effusion of blood between the pericranium 
and the skull-cap. The pericranium and scalp are raised into a 
distinct tumor. In external cephalhematoma the effusion is betweeu 
the pericranium and the skull ; in internal cephalhematoma it is 
between the dura mater and the skull. Kee found both forms pres- 
ent in the same patient in 9 out of 20 cases. 

Symptoms. — There is a tumor varying in size from that of a 
hazel-nut to that of an orange, of elastic consistency, situated in most 
cases on one or the other parietal bone. It is round, elongated, or 
kidney-shaped. It covers part or the whole of the bone, but never 
extends beyond the sutures. The skin over the tumor is not sensi- 
tive to the touch, is normal or slightly bluish in color, and is perfectly 
movable over the tumor. After a few days the circumference of the 
tumor is bounded by a distinct wall, at first soft, but later of bony 
hardness. The general health of the infant remains good unless 
there is a complication. This blood tumor appears two or three 
days after birth. At first it is tense, but afterward becomes softer 



11(3 DISEASES OF THE NEWBORN INFANT. 

and doughy to the touch. It reaches its maximum size in from 
six to eight days. It begins to diminish in the second week, and 
disappears by the fifteenth week. The tumor is either absorbed or 
there is a proliferation of bone, which remains as an exostosis. At 
this time crepitation resembling that of parchment is felt. Around 
the former tumor a thin wall of bone is found. 

Occurrence. — These tumors are not common. Hennig found 
230 cases in 53,506 births, or 0.43 per cent, of the whole number. 
Hofmokl's statistics give a like figure. Most of the cases are vertex 
presentations. The cephalhematoma usually occurs on the right 
parietal bone, and may follow easy as well as difficult labors. It 
is present oftener in boys than in girls, and is seen in premature 
infants as well as full-term babies. It has been observed in breech 
cases, especially if forceps has been applied to the after-coming head. 
These tumors may occur on both parietal bones of the infant. In 
such cases the sagittal suture distinctly separates the two tumors. 

Complications. — Internal cephalhematoma, or cerebral hemor- 
rhage, may complicate the external tumor. In such cases there has 
been a difficult labor with the application of forceps. The majority 
of the infants thus affected die. Suppuration of the tumor may take 
place, or diffuse cranial phlegmon may result fatally. A section of 
a cephalhematoma shows the scalp to be studded with punctate 
hemorrhages. The pericranium is bluish and covered with hemor- 
rhages, and is separated from the skull by a collection of fluid blood 
under great tension. The bone beneath is rough or covered with 
a few clots. A bony wall is seen around the circumference of the 
tumor. It is a periosteal formation. After a time the bone and the 
inner surface of the pericranium become coated with a gelatinous 
exudate, which is subsequently converted into bone. In some cases 
quite an extensive bloody effusion is found between the dura and 
skull. 

The situation of the cephalohsematoma always corresponds to the 
position of certain natural fissures which exist in the posterior part 
of both parietal bones, running from the sagittal suture. In the 
occipital bone these fissures radiate from the lateral fontanelles and 
separate the upper and the inferior part of the occipital bone. 

Pathogenesis. — A cephalhematoma is the result of the bursting 
of a small vessel between the periosteum and bone, and at the situa- 
tion of the caput succedaneum. Hence the frequent formation of 
the tumor on the right parietal bone. It is most common in first- 
born infants. Asphyxia of the infant favors the formation of the 
tumor. Cephalohsematoma may also occur as a part of the hemor- 
rhagic symptomatology in general diseases, such as syphilis, sepsis, 
and Buhl's disease. 

The diagnosis is made in the presence of an elastic fluctuating 
tumor distinctly limited by suture and surrounded by a ring or wall. 






CEPHALOHMMATOMA. 117 

A caput succedaueum is (edematous and bluish, is seen immediately 
after birth, passes beyond the sutures, does not fluctuate, and disap- 
pears shortly after birth. A hernia of the brain does not fluctuate, 
grows tense when the infant cries, and shows respiratory fluctuations 
and pulsation. It can be reduced. Abscess of the scalp is painful, 
hot, and red ; the phlegmon spreads over the whole scalp and is 
accompanied by oedema of the whole region. If cerebral symptoms 
are present with a cephalhematoma, they point to corresponding 
internal effusion or cerebral hemorrhage. 

The prognosis is good if there is no internal tumor or cerebral 
hemorrhage, or if infection of the external tumor with resulting 
abscess does not occur. Even the latter, however, does not preclude 
the possibility of recovery. The prognosis is bad if the cephal- 
hematoma is part of a general hemorrhagic condition, as in syphilis, 
fatty degeneration, or sepsis. 

Treatment. — Uncomplicated cephaloha?matomata are absorbed 

if let alone. If abscess occurs, the tumor should be opened under 

antiseptic precautions, evacuated, and the sac packed with iodoform 

gauze. 

On the other hand, even in the early stage, the tumor may be large and 
tense, and cerebral symptoms may be present. Such effusions of blood may 
communicate with an internal tumor through the parietal or occipital fis- 
sures mentioned. In such very exceptional cases aspiration to relieve internal 
pressure may be justifiable (Range). 

Leading Authorities Referred to ra Chapter II. 

Berlin, G. : Infections des Xonveau nes dans le couveuse, Paris, 1899. 

Escherich, T. : "Trismus et Tetanus," "Wien. klin. Wochensclir., 1893. "Brut- 
kammer fur friihgeborenen," etc., Mittheil. Vereins Steiermark, No. 3, 1900. 

FischljR.: "Infection Septique," Traite Maladies des Enfants, Comby, 1896. 
Prophylaxe der Krankheiten des Kindesal'ters, Nobling, Jankau, 1900. 

Landau, L. : Melaena der Xeugeborenen, Breslau, 1874. 

Mosehowitz, A. V.: ''Tetanus,'' Annuls of Surgery, 1900. 

Pascaud, V. ; La Couveuse Artilicielle. Paris, 1899. 

Runge, M. : Die Krankheiten der Ersten Lebenstage, 1893. 

Vnnrhees, J. D. : " Care of Premature Babies in Incubators," Arch, of Pediat., 
May, 1900. 



CHAPTER III. 

THE SPECIFIC INFECTIOUS DISEASES. 

THE EXANTHEMATA. 

The exanthemata, scarlet fever, measles, Rotheln, varicella, and 
variola, are acute specific infectious diseases. They form a distinct 
group. The poison or infectious element originates in the body 
of the patient. The nature of this poison is unknown. Though 
suspected to be bacterial, the essential cause in any of the exan- 
themata has not been isolated. We do know, however, that the 
acute exanthemata are conveyed from one person to another through 
the medium of the atmosphere. In this respect they differ essentially 
from such diseases as typhoid fever, or even syphilis, in which the 
morbific agent must be introduced into the body. They are there- 
fore contagious in the true sense of the term. Most people are sus- 
ceptible to some of the exanthemata, such as measles and smallpox. 
On the other hand, not every one exposed to contagion will contract 
scarlet fever or varicella. Few persons are attacked twice by the 
same exanthematic affection, but there are exceptions to this rule. 
An attack of one disease, such as measles, does not confer immunity 
from an attack of another, such as scarlet fever. The exanthemata 
occur either endemically or epidemically. Each has a well-defined 
period of incubation — that is to say, an interval between the time of 
the exposure to contagion and the onset of characteristic symptoms. 
In the different exanthemata this interval varies within wide limits. 
The period of incubation seems to be more accurately determined in 
measles than in the other exanthemata. It is well established that 
two of the exanthemata may occur at the same time in the same sub- 
ject. This is not a point in favor of the identity of the essential 
cause of the exanthemata. On the contrary, it is an accepted fact 
that each of the exanthemata is distinct in itself, and that each dis- 
ease has its specific essential cause. The exanthemata are character- 
ized by an eruption on the skin, the so-called exanthema, or rash. 

SCARLET FEVER. 

Scarlet fever is an acute infectious disease with a characteristic 
rash or exanthema. It is highly contagious. 

Etiology. — It has not as yet been established whether the infec- 

118 



SCARLET FEVER. 119 

tious agent is a micro-organism, although streptococci have been 
isolated from the secretions and scales in the desquamative period. 
Neither do we know whether there is an organism in the circulating 
blood. The atmosphere about the patient seems in most cases to be 
the zone of contagion. The nearer a person has been to the patient 
the more likely is he to convey the disease to a third person. 
Articles of clothing may retain the infection for months. Scales 
from the skin of the patient, dried secretions, the urine if nephritis 
exists, and feces are also mediums of infection. The longer the 
physician remains near the patient the more likely is he to convey 
the disease. This mode of infection occurs. Osier records his 
belief in having carried infection to a patient. Foodstuffs handled 
by those suffering from the disease or by those who have been near 
patients may convey the disease. This is especially the case with 
milk, which is said to have been the cause of epidemics in England. 
The poison of scarlet fever seems to pervade the ward or sick-room 
for a long time. AYhether this period extends over two years, as 
recorded by Murchison, is a matter not yet settled. AVe do not yet 
know how the poison obtains entrance to the body. The discharge 
from a scarlatinal otitis is said to be capable of communicating 
the disease. 

Susceptibility. — All children exposed to infection do not con- 
tract the disease. It is less contagious than measles. On the 
other hand, although a person may be exposed once and escape, he 
is not necessarily immune to future exposures. A nurse attended 
many cases for me before contracting the disease. As a rule, one 
attack of scarlet fever protects a person from subsequent attacks. 
The literature records cases of well-observed second and third 
attacks. The author has met cases of a second attack. AVe' should, 
however, be cautious in accepting reports of repeated attacks. 
Rotheln may have been mistaken for scarlet fever. 

Occurrence. — Scarlet fever occurs at any age, and in all coun- 
tries, being endemic in North America and Europe. It is most 
prevalent in autumn and winter (September to February). It 
remains endemic wherever introduced. Sporadic cases occur. It 
occurs also in epidemics. In epidemics only 38 per cent, of the 
population are affected. There is therefore an immunity of the 
majority (Jurgensen, on the Faroe Epidemics). As a rule, fully 56 
per cent, of those exposed before the twentieth year contract the 
disease. 

Incubation. — According to the German authorities, scarlet fever 
has an incubation period of from eight to eleven days. Eng- 
lish authors (Murchison) fix the period at from three to six days. 
The vast majority of cases develop within a period of from three 
to five days after exposure. If eleven days elapse without the 
appearance of symptoms, we may with reasonable certainty say that 



120 THE SPECIFIC INFECTIOUS DISEASES. 

the danger is past. Cases of thirty days' incubation are recorded, 
and the author had a case in his practice in which a physician con- 
veyed the disease, the boy being attacked three weeks after his visit. 
In all such prolonged periods of incubation, however, there is a 
probability of a more recent exposure. The contagion is active dur- 
ing the period of incubation and during the eruptive and desquama- 
tive stages. The consensus of opinion is that the contagion dimin- 
ishes in the desquamative stage. We should exercise great caution 
in allowing convalescents to communicate with the healthy. Strange 
to say, there are no positive data on this point. Contagion will be 
treated more fully under Prophylaxis. 

Immunity. — Although there is no absolute immunity at any 
age, scarlet fever attacks nursing infants less frequently than older 
children. We have no positive data as to transmission of the affec- 
tion in utero. Cases are recorded in which the newly born infant 
has been attacked, but some authors are inclined to look on such 
cases with doubt. In certain sets of cases the affection takes on a 
virulent form — cases in families in which all the members attacked 
will have complications, septic or otherwise, of a fatal character. 
An instance came under the author's notice in which during a very 
ordinary epidemic of scarlet fever one family lost two of three 
children attacked. All had septic malignant fever. There may in 
such cases be an element of mixed infection (Henoch). 

Symptomatology. — Scarlet fever does not present uniform 
symptoms. A general description of the disease can hardly be 
given without misleading the student. During an epidemic or dur- 
ing the prevalence of scarlet fever, there are a number of cases of 
angina in which no exanthema of scarlet fever is seen. This is 
especially so with those whose duties keep them near scarlet fever 
patients. There is no doubt that such anginal cases are capable 
of conveying the disease to others. A case of this kind has come 
under the author's notice. A nurse suffering from an angina went 
from a scarlet fever case to a healthy child. Although the nurse had 
taken all external precautions she conveyed the disease to the child. 
This raises the question of scarlet fever sine exanthema. Let us 
say that scarlet fever poison can cause a specific angina capable of 
conveying the disease to the healthy. Certain forms of exanthema 
of scarlet fever are very evanescent, and in anginal cases may 
escape observation. 

The period of incubation has no fixed symptomatology. In 
many cases the symptoms begin with the appearance of the eruption. 
The children play about ; they have a slight angina, but do not 
complain. This is apt to be the case with children who are suf- 
ferers from chronic catarrh, enlarged tonsils, or adenoids. In other 
cases the invasion of the disease is a stormy one. There may be an 
initial convulsion preceded by a sharp rise in temperature. Exami- 



SCARLET FEVER. 



121 



nation in such cases may show, previous to the appearance of the 
eruption, a marked angina or a membranous deposit on the tonsils, 
but nothing more. Other children suffer from a tonsillitis of mod- 
erate severity, a marked febrile movement, and, what is character- 
istic, attacks of anorexia and vomiting. A chill, followed by fever 
and vomiting, ushers in a large number of scarlatinal anginas. 
Occasionally the symptoms of invasion are so mild and evanescent 
as to escape the notice of even watchful parents. These are the 
cases in which the first symptom to attract attention belongs to a 
later period of the disease or to some of the complications. There 
are thus all degrees in the severity of the symptoms of the period 
of invasion, varying with the susceptibility of the subject and the 
virulence of the epidemic. 

General Course of the Disease. — An attack of scarlet fever 
takes a certain general course. After the initial symptoms described, 

















Fig. 


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Moderated severe scarlet fever ; female child four years of age. Normal course. Observed 

from the outset. 



twelve to thirty-six hours elapse, when an eruption or rash appears 
on the skin : this eruption, though characteristic, varies greatly in 
intensity, mode of spreading, and distribution. The fever is now 
very high ; the eruption spreads and becomes more intense and gen- 
eral (Fig. 28). At the greatest intensity of the eruption or flores- 
cence the fever is highest. In typical cases of scarlet fever the 
eruption reaches its full development and runs its course within 
two to six days. At the end of this time it fades, and desquama- 
tion begins. The fever subsides gradually, leaving the patient con- 
valescent. The period of invasion is not so sharply defined as in 
measles, nor is the stage of eruption so distinct and uniform as in 
that disease. The length of the period of desquamation in both 
measles and scarlet fever vari 



122 



THE SPECIFIC INFECTIOUS DISEASES. 



The malignant cases may at first appear mild. The children are 
taken with vomiting and a moderately high fever, and the eruption 
appears. While the eruption is spreading, however, the patients 
become stupid, and within a few hours after the appearance of the 
exanthema pass into a state of coma. The urine is diminished in 
quantity or suppressed, and contains blood, albumin, and casts. 
The temperature remains elevated (Fig. 29). The pulse is rapid 
and at times thready. These patients remain comatose and die 
within a few days (three or four) of the onset of the symptoms. In 
other malignant cases the affection of the throat and adjacent lymph- 
nodes is a leading factor in the septic phenomena, while the kidneys 
show very little participation in the general toxaemia. Such patients 
will show necrotic pseudomembranous inflammation in the fauces 
after the eruption is fully developed. The glands of the neck are 



Fig. 29. 


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Malignant scarlet fever; ursemic symptoms from outset. Boy, six years. Sopor increas- 
ing to coma ; bloody urine. Involuntary passage of urine and feces. Death in three days: 
after onset of symptoms. 



involved. The temperature ranges from 103° to 105° F. (39.4° 
to 40.5° C), with daily remissions. The patients have a sallow, 
septic appearance, and are stupid and irritable. The exanthema fades 
slightly after having been in efflorescence. The lymph-nodes in the 
neck enlarge to great size. These patients may die in the second 
week from general toxaemia. Between the normal course and these 
malignant forms there are all degrees of severity and mildness in 
this affection. 

We shall now consider the various phenomena of the disease. 

The Angina. — The angina of scarlet fever is limited to the pillars 
of the fauces, the uvula, the tonsils, and retropharynx. With this 
there may be a slight suffusion of the eyes. The angina may be 
simply a slight redness of the fauces and very slight swelling of 
both tonsils. The lymph-nodes at the angle of the jaw may be 



SCARLET FEVER. 123 

very slightly enlarged. The tonsils may be so greatly enlarged as 
to close the opening of the fauces. This is likely to be the case if 
there has been antecedent hypertrophy of the tonsils. No mem- 
branous deposit may be seen, yet there may be a distinct lacunar 
form of tonsillitis. The lymph-nodes at the angle of the jaw may 
be much larger than in the milder anginal cases. The swelling of 
the lymph-nod js may involve the connective tissue about them in a 
phlegmonous mass. This is especially so in the severe septic forms 
of scarlatinal angina of the streptococcus variety. 

Membranous Axgixa. — Membrane spreading to the pillars of 
the lances may be present on one or both tonsils. This condition 
was formerly called scarlatinal diphtheria. In the vast number of 
cases of scarlet fever — in fact, in all the uncomplicated cases — this 
membrane is not a true diphtheria like the diphtheria of Loffler. 
It is a streptococcus membrane (diphtheroid), caused by the strepto- 
coccus of pseudomembranous formations. This membrane may 
involve the posterior pharynx and nares, and spread downward into 
the larynx and trachea. True diphtheria of Loffler occurs in those 
cases of scarlet fever which have been exposed to the infection of 
diphtheria at or about the time of the outbreak of the scarlet fever 
or at some period during the course of the disease. The membrane 
in these cases will show, on examination, the Bacillus diphtheria? 
of Loffler. These cases of true diphtheria complicating scarlet fever 
are exceptional, and presuppose an exposure both to diphtheria and 
scarlet fever. The pseudodiphtheria is usually caused by a strepto- 
coccus of the scarlatinous variety. In some forms of scarlet fever 
this pseudomembranous inflammation of the tonsils becomes a pri- 
mary factor in the disease at an early period before the full devel- 
opment of the eruption. This process involves the lymph-nodes 
and the whole connective tissue of the neck below the jaw in a 
necrotic streptococcus inflammation. In many cases a true strep- 
tococcaemia may result from the entrance of the streptococci into 
the circulation. In other cases the patient may have passed through 
the eruptive stage and the process originating in the tonsils may 
play a leading role in the disease. Retropharyngeal abscess, medi- 
astinal burrowing abscess, abscess pointing on the external portion 
of the neck, or empyema, may result from the necrotic tonsillar 
affection by extension through the lymph-nodes. Secondarily, a gen- 
eral systemic infection may result in such cases. 

The mucous membrane of the mouth presents nothing character- 
istic in the great majority of cases of scarlet fever. The buccal 
mucous membrane is pale, and of a normal hue at first ; the soft 
palate may present a few red, irregularly shaped spots or red 
streaked areas, or these may be absent. Later in the course of the 
disease a stomatitis may appear. This is more likely to occur in 
the so-called septic cases. In these the superficial epithelium is 



124 THE SPECIFIC INFECTIOUS DISEASES. 

removed ; the mucous membrane has a dry, red, beefy appearance. 
The lips are fissured and bleed easily. 

The tongue in most cases of scarlet fever is furred at the outset, 
and may present a slightly reddened appearance at the borders and 
tip. Only occasionally do Ave find the so-called characteristic straw- 
berry tongue. This shows an undue prominence and erection of the 
papillae of the tongue, especially at the tip. The tip is red, and 
with the prominent papillae gives the appearance of a strawberry or 
of the tongue of the lower animals (cat). In many cases the tongue 
later becomes denuded of epithelium and shows the erected papillae 
on the dorsum ; in others it becomes dry and fissured. The latter 
condition is seen in the fatal toxic cases. 

The Exanthema. — The exanthema of scarlet fever, though very 
characteristic in appearance, varies more than in any of the other 
exanthemata in mode of appearance, distribution, spreading, and 
in duration. In the mild cases the eruption is sometimes- so 
evanescent as to escape notice. In other cases it appears only 
on certain parts of the surface. It may be very discrete in 
form and punctate. Usually it first appears on the upper part 
of the chest about the clavicles, spreads down the chest, and 
around upon the back. At this time it is also seen on the 
neck, beneath the jaw, behind the ears, and on the temples. 
It consists of a very finely punctate rose-colored rash. The 
punctate appearance is the distinguishing feature of the eruption. 
At the outset this punctate character is best observed on the chest, 
abdomen, and the nates. If the eruption has in places become 
confluent, the skin shows a uniform redness. In such cases the 
punctate character of the rash can best be discovered by studying 
the skin from a distance in bright daylight. It will then be made 
out distinctly in those places in which the rash is most recent. A 
favorite method is to completely undress the patient and study the 
lower abdomen, the thighs, and nates. In the early cases the 
punctate character of the rash is apparent on the neck and behind 
the ears. The appearance of the face at the outset of the dis- 
ease is characteristic. There is a pallor about the mouth and 
alae nasi, while the cheeks are flushed with a flame-like ery- 
thema. The cheeks do not show the characteristic punctate rash, 
although flushed either from the fever or intense dermatitis, which 
involves the whole surface. The eruption spreads from above down- 
ward, involving the arms and forearms, hands, and lower extremities. 
It retains the punctate character wherever it spreads, but loses this 
characteristic after it has been out for a short time and become con- 
fluent. When confluent the rash causes the skin to appear uniformly 
red and swollen. The skin is roughened in patches by the erection 
of the papillae. In other cases, and especially in those occurring in 
summer, the skin is studded with myriads of minute vesicles. In 



SCARLET FEVER. 125 

other cases the skin may present minute pustules. There is pruritus 
in the cases in which the dermatitis is severe. The rash of scarlet 
fever attains its full development at the end of two or three days. 
It is then said to be in efflorescence. It remains out a variable 
length of time, in some cases six days. In other cases the eruption 
may develop fully in two days and then fade. Cases in which the 
rash is visible for only twenty-four hours are not uncommon. The 
appearance of a fading scarlet fever rash is very characteristic if it 
has involved the whole surface. The skin is dotted here and there 
by raised papilla?, and appears as if irregularly and lightly daubed 
with rouge. Even a fading rash may be easily diagnosed by an 
experienced observer. In mild cases the rash may disappear within 
twelve hours, leaving no vestige of its presence. In other cases the 
rash appears only on the lower part of the abdomen and upper part 
of the thighs. 

The eruption on the lower part of the extensor surface of the 
forearms, and also on that of the legs, is apt to assume a blotchy, 
roseola-like appearance. Such cases have been mistaken for measles. 

Abscesses or furuncles, multiple or single, may involve the skin. 
In rare cases gangrenous processes have been recorded. A secondary 
infection may be assumed in all of these cases. 

The Fever. — In the first few hours there is a rapid rise of 
the temperature to 104° or 105.8° F. (40° or 41° C.) It 
remains high with morning remissions until the eruption on the 
surface reaches its full development. With the fading of the erup- 
tion the temperature falls, and within six days, if the case is uncom- 
plicated and typical, becomes subnormal. The patient may show a 
subnormal temperature for a few days, after which it may rise to the 
normal. In some cases the temperature may rise very rapidly, 
reaching its highest point within a few hours. It may then fall to 
the normal rapidly, though the eruption be still present. Wunder- 
lich and Henoch record cases of profuse exanthema with a mild 
febrile course or practically afebrile curve, 101.1° F. (38.4° C), 
falling rapidly to 100.4° F. (38° C.) within twenty-four hours. 
In those cases in which there are complications either in the throat, 
ear, joints (rheumatism), or serous cavities, the temperature-curve 
will be influenced accordingly. In other cases, evening remissions 
may occur instead of morning ones. After the fading of the erup- 
tion the fever may continue for days, 100.4° to 102.2° F. (38° to 
30° C), in the absence of any complication. After days or weeks 
of absence of temperature there may occur a distinct rise and 
a species of relapse similar to that seen in typhoid fever. This 
is probably due to a form of secondary streptococcus infection. 
During the height of the eruption the temperature may reach 107° F. 
(41.6° C), although in mild eases it may not be over 103° F. 
(39.4° C). In cases of septic infection, especially of the lymph- 



126 



THE SPECIFIC INFECTIOUS DISEASES. 



nodes, or in streptococcus diphtheria, with infection of the lymph- 
nodes, the temperature-curve will be of a remittent character, fall- 
ing and rising once or twice in twenty-four hours, and may retain 
this character throughout the affection. Uraemia or any affection of 
the pleura, lungs, or heart will be ushered in by a rise of temperature 
even if it has returned to the normal. If a complication occurs early 
in the disease, the temperature will fail to drop to normal with the 
fading of the eruption (Fig. 30). In cases of otitis persisting 
through the stage of desquamation there will sometimes be an 
evening rise, although the ears are discharging freely. In such 
cases the bone may be involved (mastoid disease). In severe, malig- 
nant forms in which symptoms of profound sepsis, such as coma or 
stupor, are present from the outset, the temperature remains persist- 
ently high (105.6° F., 40.8° C), remitting a degree toward morn- 
ing. The temperature remains high until the fatal issue (see Fig. 29). 





















































Fig. 


30. 




























































DAY OF 
DISEASE 


1 


2 


s 


4 


5 


6 


7 


8 


9 


10 


11 


12 


13 


14 


15 


HOUR 


" 


-; 


- 


2 


. 


- 


- 


s 


■ 


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Scarlet fever, moderate severity, in a boy six years of age. Shows the delay in the drop 
of the temperature due to complicating otitis of the right ear at the outset of the period of 
desquamation. 



Desquamation. — The period of desquamation begins as soon as the 
exanthema commences to fade. Generally speaking, since the 
exanthema first appears on the upper part of the chest and neck 
we should expect desquamation to begin there. It may be in fine, 
branny scales, such as are seen in measles ; or else, as is most com- 
mon, the skin peels in larger particles. The hands and feet show the 
largest scales, and complete casts of the hands and feet are some- 
times shed. I have seen the nails shed completely twelve weeks 
after the attack. The desquamation may be scarcely perceptible. 
In some cases only certain parts of the extremities, such as the toes 
or inner portion of the thighs, show desquamation. It is, however, 
always present. Desquamation in itself is not a pathognomonic 
symptom of scarlet fever. It occurs in forms of dermatitis which 
bear no relationship to the disease. It is still a subject of debate 
whether cases of angina without an exanthema may desquamate. 
Henoch is inclined to think this possible. We should remember 



SC ABLET FEVER. 



12" 



that au evanescent, slightly marked exanthema may escape the notice 
of even the most careful observer. 

The duration of desquamation is variable. I have seen the skin 
desquamate a second time. The severity of desquamation has no 
relation to the intensity of the exanthema. Some very marked cases 
of scarlatina desquamate less than those in which the eruption has 
been faintly marked. 

The Nose. — The close relationship of the nasal passages to the 
pharynx facilitates the invasion of bacteria from the throat. The 
nasal passages become affected simultaneously with the severe angina. 
There is a severe catarrhal or pseudomembranous inflammation of 
the mucous membrane. In the so-called septic cases there may be 
an ichorous discharge from the nostrils. There will be in such cases 
erosions, and sometimes fetor, with the discharge of necrotic tissue 
through the nasal passages. Necrosis of the cartilaginous and bony 
structures may result. In other forms there is a pseudomembranous 
deposit around the opening of the nostrils extending up into the 
nasal passages. Casts of the nasal passages may be expelled. The 
membrane may leave a bleeding surface. 

Ear. — Duel found the ears aifected in 20 per cent, of the cases 
of scarlet fever. Generallv both ears are diseased. Deafness 





















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Female child, two and a half years of acre. A mild form of scarlet fever complicated in the 

second week by an otitis. 

is frequently a result of otitis. Ten per cent, of those who suffer from 
deaf-mutism can trace their affliction to scarlet fever. Usually the 
ears become affected in the third week, although they may be in- 
volved at the outset of desquamation. The affection of the ears is 
ushered in by a rise of temperature and manifestations of pain (Fig. 
31). Occasionally tinnitus and deafness are initial symptoms. 
There may be convulsions or even cerebral symptoms. The onset 
of ear trouble may be insidious, and not suspected until the purulent 
discharge makes its appearance. If there are premonitory symp- 
toms, they may precede the perforation by one to three days. Ear 



128 THE SPECIFIC INFECTIOUS DISEASES, 

complications in scarlet fever are always of serious moment. Men- 
ingitis, sinus thrombosis, and abscess of the brain are among the 
more serious results, and may result long after the fever has run its 
course. The onset of otitis usually occurs during the period of 
desquamation. The patient may be up and about. There is still 
some redness of the throat, with swelling of the lymph-nodes. There 
is a sudden rise of temperature to 103° or 104° F. (39.4° or 40° 
C). The child begins to vomit food and has headache. At night 
the child starts from sleep and cries as if in pain. Children do not 
always locate the pain in the ear. The reason is that the pain occurs 
before the child is quite awake. The sleep is restless. The muscles 
of the face and hands twitch in sleep. These symptoms may at 
times abate. The temperature may fall to the normal and then rise 
sharply. Any of these symptoms should direct attention to the ear. 

The mastoid may become the seat of inflammation in the fifth or 
sixth week. The ears may have been discharging very freely. The 
child is not, however, free from fever. At times during the day 
the patient complains of frontal headache, is drowsy, and the tem- 
perature shows a rise to 102° or 103° F. (38.5° or 39.9° C). 
There is tenderness behind the ear or in front of the auditory 
meatus. There may be a slight blush above and behind the pinna. 
In these cases the mastoid may be the seat of suppuration. There 
are forms of otitis which occur on the eighth day of the disease. The 
temperature does not fall to the normal. The patient has begun to 
desquamate, but the temperature remains elevated a degree or more 
and takes fully three or four days longer to fall to 99° F. (37.2°" 
C.) in the rectum than in an uncomplicated case. At the eleventh 
day of the disease pain is complained of. The drumhead is found 
to be bulging. An insidious serous otitis media is in progress. 

The Eye. — Conjunctivitis may appear in some cases of scarlet 
fever as a result of a mixed infection. The lachrymal duct is the 
canal through which such infection travels. Conjunctivitis in cases 
of gangrenous pharyngitis and rhinitis may lead to panophthalmitis 
and destruction of the bulb. 

Lymph-nodes. — The lymph-nodes in various parts of the body 
enlarge in scarlet fever. Those situated at the back of the neck 
behind the posterior border of the sternomastoid muscle may enlarge 
some days before the appearance of the exanthema. At the time of 
the eruption w T e may find the lymph-nodes in the axilla, inguinal 
region, and those at the angle of the jaw, enlarged. In other cases 
the lymph-nodes, except those at the angle of the jaw, may not be 
perceptibly enlarged. In some cases the lymph-nodes at the angle 
of the jaw may enlarge at the end of the second week, with a dis- 
tinct rise of temperature to 104° F. (40° C.) or more, as a result of 
reinfection through the tonsils and pharynx. The connective tissue 
of the neck beneath the body of the jaw is involved in the inflamma- 



SCARLET FEVER. 



129 



tion of the nodes. In such cases the swelling has an appearance similar 
to that seen in angina Ludovici. In severe mixed infection the tissues 
of the neck may become gangrenous. As a result of such severe 
gangrenous inflammation, phlebitis erosion into the veins and arteries 
with fatal hemorrhage may result. Retropharyngeal abscess or retro- 
pharyngeal adenitis is a sequence of infection of the lymph-nodes. 
The retropharyngeal abscess in such cases is not as benign as that 
occurring independently of scarlet fever. In the latter the abscess 
is apt to involve a chain of retropharyngeal nodes. Multiple bur- 
rowing abscesses result. The nodes of the mediastinum may be 
affected, causing empyema or pericarditis. The mediastinal abscess 
may cause death by pressure on the trachea, or, by eroding the 
trachea, burst into it and cause death through suffocation. 

The Mouth. — Stomatitis always occurs in severe scarlet fever. It 
may be simply a mild catarrhal process. If there is a pseudo- 
membranous formation on the tonsils, this pseudomembrane may 
spread to the mucous membrane of the soft palate, and the buccal 
mucous membrane may also become affected. The tongue is dry 
and fissured ; the lips are dry, fissured, and bleed easily. There 
mav be a discharge of necrotic tissue from the mouth. The soft 
palate, tonsils, and pharynx may be fused into a necrotic mass, emit- 
ting an offensive odor. 

Joints. — The joints become inflamed in from 2 to 6 per cent, of 
the cases of scarlet fever. This affection of the joints has been called 

Fig. 32. 




Boy five years of age, observed from the outset of the disease. Scarlet fever with joint-com- 
plications. Xo cardiac involvement. Recovery. 

scarlatinal rheumatism. The joint-affection may, in exceptional 
cases, precede the exanthema. It appears, as a rule, in the second 
or third week of the disease (Fig. 32), and is therefore one of the 
manifestations seen during desquamation. There may be pain in 
several articulations. In other eases swelling may occur, with effu- 
sion of serum into the joints. These cases retrograde. There may 
be a complicating endocarditis. In other cases there is suppuration 
of the joint. An arthritis with streptococci in the joint-effusion 
results. The streptococci invade the joint through the epiphyses of 
the bone, and produce a streptococcus osteomyelitis with suppuration 
of the adjacent joints (Lannelongue, Achard, Koplik, Van Arsdale). 



130 THE SPECIFIC INFECTIOUS DISEASES. 

As a rule, suppuration occurs in only one joint. Cases in which 
several joints are affected are generally septic, streptococci having 
gained access to the general circulation through a necrotic focus in 
the throat or pharynx. Such cases are fatal. There are metastases 
in the lungs, kidneys, pleura, and pericardium, with hemorrhages in 
the skin and enlargement of the spleen. Periarticular abscesses rarely 
occur (Henoch). The prognosis is serious in all suppurative cases. 

The Kidneys. — In scarlet fever, as in most infectious diseases, 
there may be a mild form of nephritis in the earlier stages. There 
are a small amount of albumin and a few hyaline casts in the urine. 
This nephritis is of little significance, and has nothing in common 
with the severer form which occurs later in the disease. The severe 
form of nephritis begins as a rule in the third week. It has been 
known to appear in the sixth week. The frequency of this compli- 
cation varies in different epidemics. In some, only a small number 
of cases are affected (5 per cent.). In other epidemics fully 70 per 
cent, of the cases are thus complicated. Its occurrence cannot 
always be predicted from the severity of the disease. The mildest 
cases may develop severe nephritis. The diphtheritic forms of 
angina are more likely to be complicated with or followed by 
nephritis. On the other hand, the severest forms of scarlet fever 
may run their course without marked nephritis. Sorensen has 
shown that at autopsy the most marked changes may be found in 
the kidneys, although no clinical signs of the affection have been 
manifested during life. In 50 per cent, of the autopsies upon scarlet 
fever patients Friedlander found changes in the kidneys. It was 
formerly thought that exposure played an etiological role in this affec- 
tion, but this view has been abandoned. Nephritis may develop in 
cases which have been very carefully guarded from exposure from 
the outset. Although the symptoms will be detailed elsewhere, it 
may be here stated that the first symptom is a slight oedema about the 
eyes and face which spreads to the rest of the body, involving the 
trunk and extremities, the hands and dorsum of the feet, and the 
scrotum. In some cases the oedema is not marked, in others the 
anasarca is extreme. The serous cavities may become the seat of 
effusion, and there may be hydrothorax, hydropericardium, or ascites. 
The urine also shows changes very early. The quantity diminishes 
very rapidly, or it may be completely suppressed. The urine shows 
the presence of albumin, rarely more than 0.5 per cent. It may be 
highly colored or smoky, or may be distinctly red in color, owing 
to the large amount of blood and blood-pigment contained. The 
urine in cases of partial or complete suppression generally contains 
a large amount of albumin, blood, hyaline, epithelium, and blood- 
casts, renal epithelium, and leucocytes. The specific gravity may 
at first be high, 1.030; later, when diuresis is inaugurated, it may 
fall to 1.006. All cases do not run their course with anasarca. 



SCARLET FEVER. 131 

Henoch has seen cases without this symptom. The invasion of the 
affection is sometimes marked either by a rise of temperature or 
convulsions. The prognosis is good in spite of the very alarming 
symptoms, such as convulsions and coma, which are seen in some 
cases. This nephritis usually runs its course in from four to six 
weeks, leaving the kidneys intact. Sometimes the nephritis appar- 
ently subsides, but albuminuria of a very mild or intermittent form 
persists for months. In fact, many of the so-called cases of par- 
oxysmal albuminuria are probably due to unnoticed scarlatinal 
nephritis. Finally, the author has seen cases in which the anasarca 
recurred at long intervals as a result of chronic diffuse nephritis. 

Uraemia. — Uraemia commonly sets in with a diminution in the 
whole quantity of urine passed daily. It may supervene without 
any distinct change in the quantity or quality of the urinary excre- 
tion (Henoch). In these cases the changes in the urine follow the 
appearance of the uraemic symptoms. Uraemia may also appear 
notwithstanding the passage of an increased amount of urine. The 
latter mode of onset in uraemia is very uncommon. The early 
symptoms are vomiting, headache, and slight twitching of the facial 
muscles. These may subside with the abatement of the nephritis. 
We may have, however, eclampsia as the first symptom, with tonic 
or clonic convulsions, unconsciousness, and coma with temporary 
absence of the reflexes. The respirations are increased, and in most 
cases the temperature rises. The pulse is small and the skin dry. 
The convulsions may subside, but the coma may continue. The 
eclamptic seizures may be repeated. The uraemia may subside, and 
after a very protracted interval reappear with a repetition of the 
above phenomena. Mania, melancholia, and aphasia may ensue. 

Amaurosis without changes in the retina is a more common con- 
dition. The retinitis of Bright' s disease is absent in scarlet fever. 
Litten found a swollen condition of the papilla. Amaurosis may 
persist in the intervals between the convulsions. 

The heart action immediately preceding the convulsions is slow. 
The pulse may be as low as 40 per minute. During the convulsions 
the heart action is increased. The respirations may be 60 and the 
pulse 200 (Jurgensen). 

The temperature mav be 100.4°-103° F. (38°-39.5° C), rarely 
107.6° F. (42° C), with an initial chill (Jurgensen). 

Uraemia may set in at any time while the kidney is affected. 

The Heart. — Myocarditis of an acute infectious character is likely 
to supervene in septic cases of scarlet fever. The changes in the 
myocardium may also be secondary to changes in the pericardium 
and endocardium. 

Endocarditis of the cardiac walls is more frequent than that of 
the valves. For this reason murmurs should be carefully observed. 



132 THE SPECIFIC INFECTIOUS DISEASES. 

No conclusions as to their valvular origin can be reached until long 
after convalescence. Endocarditis is uncommon, but is more fre- 
quent in this disease than in diphtheria or typhoid fever. 

Pericarditis is rare. Muscle murmur is often mistaken for it. 
If present, pericarditis is usually of the dry fibrinous or serofibrinous 
variety. It is rarely purulent, except in cases of marked purulent 
involvement of other organs and cavities, notably the pleura. 

Dilatation of an acute character may supervene early in severe 
cases. In such cases we may have tachycardia or bradycardia. 
There may be cyanosis. Sudden death is very rare in scarlet fever. 

Friedlander has shown that in scarlet fever with marked neph- 
ritis and uraemia, the consequent increased arterial tension results in 
dilatation of the left ventricle, with slight hypertrophy. The weight 
of the heart is increased 40 per cent. The pulse may be slow and 
irregular. As the nephritis subsides the tension diminishes and the 
frequency of the pulse increases. Hypertrophy being the result 
of long-continued increased tension, can be demonstrated only in 
extreme cases. Dilatation is rarely so great as to cause death. 

Lungs. — The lungs may be affected by pneumonia, which is gen- 
erally of the bronchopneumonic type. Lobar pneumonia as a com- 
plication of scarlet fever is rare. Gangrene of the lung may occur 
in the severe septic cases. 

Pleura. — Pleuritis as a complication of scarlet fever usually 
appears in the middle of the second week. It is commonly of the 
serous variety, but the author has had many cases in which there was 
an empyema usually of the streptococcic variety. Fiirbringer 
has shown that in 5 per cent, of the cases of pleurisy there is neph- 
ritis. 

The Blood. — There is a diminution of the haemoglobin, which is 
marked in cases in which nephritis is present. During convales- 
cence the haemoglobin increases. Slight leukocytosis is also present 
in the course of the disease. There may be purpura and surface 
hemorrhages. 

Stomach and Intestine. — Vomiting has been mentioned as an 
early symptom in scarlet fever. It is sometimes repeated in the 
course of the disease if a cough due to any laryngeal or pulmonary 
complication exists. Diarrhoea is sometimes a serious complication. 
There may be a simple diarrhoea, in which an excessive number of 
movements may threaten the life of the patient early in the disease ; 
or, on the other hand, the diarrhoea may subside without serious 
results. The diarrhoea may take on a dysenteric or typhoidal type, 
with severe hemorrhages from the gut. There are some forms of 
diphtheria of the pharynx, stomach, and large intestine in the septic 
types of scarlet fever which have been described by Litten. 

Sequelae. — As sequelae to scarlet fever may be mentioned : 
which may persist for some time. 



SCARLET FEVER. 133 

Glandular Swellings. — The lymph-nodes at the angle of the jaw 
are apt to remain enlarged long after convalescence. The tonsils 
may remain large. 

Tuberculosis may follow scarlet fever. It cannot be said that 
there is any distinct connection between the two diseases. Scarlet 
fever may leave the patient more susceptible to infection either of 
acute miliary or chronic tuberculosis. 

Nervous Diseases. — Chorea has been noted by Gerhardt to follow 
scarlet fever, as have also rheumatic joint-aifections with endocar- 
ditis. 

Facial paralysis may occur as the result of prolonged otitis. 

Psychoses, such as melancholia and mania, have been noted, 
similar to those following typhoid fever or pneumonia. 

Otitis may remain with a permanent discharge and consequent 
deafness or mutism. 

The diagnosis of scarlet fever in most cases presents few diffi- 
culties ; but, on the other hand, there is no disease in which the 
symptoms are more indefinite at times. This is particularly the 
case with those patients who present an evanescent or partial exan- 
thema and only slight febrile disturbance. In some cases the diag- 
nosis must always remain in doubt. Under these conditions it is 
better to err on the safe side, and to take all precautions of isolation. 
The exanthema if partial or not very well marked is likely to be 
overlooked. The angina, which is the most constant symptom, may 
be mild. The temperature presents nothing typical as in typhoid 
fever. 

It is good practice in the presence of a localized exanthema of a 
punctate character on the thighs or lower abdomen or the upper part 
of the chest, with angina and a slight febrile movement, to consider 
the case as one of scarlet fever. In all cases of sore throat it is 
wise not to omit an inspection of the general surface. Although 
some authors have described the angina of scarlet fever as typical 
in color, the author has never found this sign of value. In some 
cases of scarlatinal angina the throat is intensely red ; in other 
cases it is of a pale-pink hue ; in still others the throat is only 
slightly inflamed. 

The enanthema is not of any service in making a diagnosis. The 
eruption on the soft and on the hard palate is not characteristic. 

Albumin in the urine is thought by some to be diagnostic of 
scarlet fever. There may be marked and unmistakable symptoms 
of scarlet fever without albuminuria. A simple lacunar amygdalitis 
may cause it. 

We must differentiate the eruption of scarlet fever from that of 
measles and rotheln, from drug eruptions, and those due to irritants. 

Measles. — In some forms of scarlet fever the eruption on the 
forearms has a blotchy appearance. Near the wrist-joint the author 



134 THE SPECIFIC INFECTIOUS DISEASES. 

has seen it closely resemble the eruption of measles. In these cases 
the punctate character of the eruption elsewhere on the surface, and 
the presence of angina, will assist us, in the absence of any enan- 
thema on the buccal mucous membrane, in coming to a conclusion. 
In measles the diffuse localization of the exanthema on the face, the 
conjunctivitis and bronchitis, will aid us. In scarlet fever parts of 
the face, such as the alse nasi and the region of the mouth, are free 
from eruption, while in measles these localities are affected by the 
exanthema. 

Rotheln. — Scarlet fever is most frequently mistaken for rotheln, 
and vice versa. 

In rotheln, when the eruption is punctate, it is invariably dis- 
crete. There is never the severe dermatitis with swelling of the 
skin found in scarlet fever. In rotheln the lymph-nodes are more 
constantly and generally swollen behind the ster no-mast o id, in the 
axillae and groin. The throat is but slightly reddened. Rotheln 
presents a normal temperature or at the most a temperature at the 
outset of the eruption of 101°-102° F. (38.3°-38.8° C.) or even 
103° F. (39.4° C), which rapidly subsides to the normal, although 
the exanthema may be spreading. 

Drug Eruptions.— Following the administration of quinine some 
children, like some adults, develop an eruption which closely re- 
sembles that of scarlet fever. In the presence of an angina and 
fever it may be difficult to exclude scarlet fever. Antitoxin of 
diphtheria, antipyrin, and belladonna also cause a rash closely re- 
sembling that of scarlet fever. It is well in such cases to discontinue 
the drug, and after a few days, the eruption having disappeared, to 
administer it again. If the patient be susceptible, there will be a 
repetition of skin symptoms. Kerosene rubbed on the surface will 
cause a punctate eruption the exact counterpart of a scarlet fever 
eruption. Among the poorer classes, with whom petroleum is popu- 
lar as a general remedy, we should think of the possibility of its 
having been used. If that has been the case, the skin will have a 
distinct odor of kerosene. 

Prognosis. — The prognosis in scarlet fever depends largely on 
the character of the epidemic and the prevalent type of the disease. 
In some epidemics in New York City the mortality has been exceed- 
ingly low — 2 to 4 per cent. (J. L. Smith), Avhile in others it has 
been notably high. In England the mortality varies from 13 to 40 
per cent. 

Personal idiosyncrasy will affect the prognosis. Some children 
develop malignant septic types of the disease although the prevailing 
epidemic is mild. 

Cases complicated with severe angina of a septic character do 
badly from the outset. 

Nephritis is a complication greatly to be feared. It may result 



SCARLET FEVER. 135 

in uraemia and death, or the acute may be followed by a chronic 
nephritis which will ultimately prove fatal. 

Otitis may cause serious and even fatal complications, such as 
brain abscess or sinus thrombosis. 

Affections of the endocardium or pleura may prove fatal. 

The prognosis of the so-called scarlatinal rheumatism is good. 
The joints, even if synovitis develops, retrograde as a rule to 
the normal in from two to three weeks. This may result even if 
high fever persists for some time during the joint-affection. In 
the presence of joint-complications it is necessary to be on the look- 
out for endocarditis or pericarditis. The occurrence of the latter 
takes place, as a rule, in cases in which there are other signs of 
septic infection, such as pleuritis and even peritonitis. All these 
are cases of mixed infection. If synovitis is complicated with such 
a serious inflammation as pericarditis, the latter is very likely to be 
purulent, and in that case the prognosis is grave. 

We should never pronounce the patient out of danger until the 
fourth week of the disease has passed without serious complica- 
tions. A very high temperature at the outset is an element of 
danger, although not necessarily so. Septic cases with high tem- 
perature and pulse above 150 in the first week of the disease are 
always to be regarded with apprehension. 

Lotz shows that the mortality is greatest under the age of one 
year and between the first and second year. The lowest mortality 
according to statistics occurs between the tenth and the fifteenth 
year. 

Morbid Anatomy. — Skin. — The investigations of Preobrachen- 
sky show that during the interval from the third day to the fourth 
week certain changes occur in the skin. These consist chiefly in an 
erythematous inflammation of the papillary layer, with hyperaemia, 
hemorrhages, and a diapedesis of erythrocytes and leucocytes. There 
is an (Edematous infiltration of the connective tissue of the skin. The 
cells of the rete Malpighii show vacuolization. There is also an infil- 
tration of the sudoriparous and sebaceous glands with small round 
cells. The epithelium of these glands desquamates and necroses. 
At the time of the eruption streptococci are found in the skin, 
especially in the vesicles of the sudamina. 

The changes in the kidneys will be considered in the chapter on 
Diseases of the Kidney. 

Bacteriology. — The parasitic nature of scarlet fever is still a 
matter for study. Streptococci play a leading rdle in the disease. 
Micro-organisms have been described in the blood (Hallier, Klebs, 
Tschamer). Others have seen plasmodium-like protozoa in the blood 
(Pfeiffer, Doehle). 

Streptococci have been found in the throat membranes (Loffler), 
in the joints (Litten, Heubner, Koplik, Van Arsdale), and in various 



136 THE SPECIFIC INFECTIOUS DISEASES. 

viscera (Frankel, Freudenberg). Streptococci have also been found 
in purulent foci of the joints and pleura (Raskin), and in the kidneys, 
in cases which have succumbed to fatal nephritis (Babes). In septic 
forms of scarlet fever these streptococci exist in the circulating blood 
(Babes, Lenhartz, Feer). Streptococci have also been found in the 
cerebrospinal fluid and bone-marrow (Baginsky). Bacteriologists, 
however, are not willing to assign to these streptococci anything but 
a secondary role, because they present no features which distinguish 
them from ordinary Streptococcus pyogenes. Kurth found that some 
of the streptococci, the so-called conglomerate-forming streptococci, 
were of a virulent type. Bretonneau, Henoch, and Heubner have 
always distinguished the diphtheria of scarlet fever from true diph- 
theria. Sorensen describes the membranous formations of scarlet 
fever as milky, yellow, smeary deposits which cannot be peeled from 
the parts. The membrane seems to penetrate into the mucous sur- 
faces. Ulcers form, and the tonsils, soft palate, uvula, and naso- 
pharynx become a necrotic, sloughing mass. Scarlatinal diphtheria 
is pre-eminently an inflammatory process with high fever, swelling 
of lymph-nodes, and suppurations in different parts of the body. 
If the larynx and trachea are affected, the bronchi rarely become 
involved. The contrary is true of Loffler diphtheria. In the latter 
the membrane can be peeled from the surface of the mucous mem- 
brane. The membrane is rich in fibrin, and spreads more on the 
surface and not in the depths. True diphtheria is followed by 
paralyses. A peculiarity of scarlet fever is that it may occur 
sporadically for years and yet not become epidemic. This is in con- 
trast to what occurs in measles. In the latter disease the affection 
may disappear almost completely and suddenly reappear in epidemic 
form (Henoch, Johanessen, Feer). Epidemics of scarlet fever are 
less common than those of measles. 

Treatment. — Prophylaxis. — The diagnosis of scarlet fever once 
made, the patient should be isolated from the rest of the family. 
If several children are affected in the same family, these children 
should be separated and not placed in one room. Otherwise rein- 
fection will occur. The clothes worn just prior to the illness should 
be sterilized in steam and then aired in the sun. Sufferers with 
angina who have been about the patient should not be allowed to 
come into contact with the healthy. All the children of the family 
should be kept from school. During the illness the bedclothes and 
linen of the patient should be put into a 1 : 5000 solution of mer- 
curic chloride, prior to being boiled and dried and aired in the sun. 
The sick-room must be kept well ventilated. There is no advan- 
tage in keeping the temperature of the sick-chamber too low. The 
author has found a temperature of 68° F. (20° C.) comfortable for 
the patient and those about him. Sunshine and fresh air are of 
more value than a room uncomfortably cool. If possible, it is well 



SCARLET FEVER. 137 

to spray with some simple cleansing solution morning and evening 
the throats of any children of the family who are not affected. 

The physician should take off his coat and vest and put on a 
linen robe of some kind before entering the sick-room. On his 
departure he should leave this robe outside the sick-room, or, better 
still, outside the window of an adjacent room. If the physician 
wears a beard, he should wash his face in a 1 : 2000 solution of 
mercuric chloride after leaving the patient. The hands should also 
be scrupulously disinfected. When he returns home he should 
make a complete change of clothing before visiting other patients. 
Carpets and superfluous furniture should be removed from the sick- 
room. The hanffins: of sheets wet with disinfectants in the door 
of the sick-room is not essential. 

Those about the sick should have no intercourse with the 
healthy, nor should they go through the house. Meals should be 
carried by others to some neutral spot. 

After convalescence the question of the disinfection of the sick- 
room and its occupation by others arises. It must be confessed that 
at present we are in possession of no absolutely sure method of dis- 
infecting a room after its occupancy by a scarlet fever patient. We 
may adopt one of two methods. The cracks and spaces in the win- 
dows and doors are closed with strips of paper glued over them. 
The disinfectants, preferably a large quantity of binoxide of man- 
ganese, table salt, and sulphur, are placed in the centre of the room. 
The sulphur is then ignited and the doors sealed. Formalin is also 
effective. After twenty-four hours the room is opened and aired, 
and the floors and walls are scrubbed with 1 : 2000 corrosive subli- 
mate. In hospitals the scrubbing is sufficient. The floor and walls 
about the bed occupied by the patient are scrubbed, and also the bed. 
The mattresses are steamed in a sterilizer constructed for the pur- 
pose. In families it is best to destroy or burn all bedding of hair. 
Rugs may be aired and disinfected by steam at the establishments 
equipped for the purpose. 

How soon may a scarlet fever patient have intercourse with the 
healthy ? We have no exact data on this important point. Some 
authors advise that after the termination of desquamation the 
patient be given a bath of 1 : 10,000 corrosive sublimate, and then 
allowed to mingle with the healthy. Others (Baginsky) advise pro- 
longed isolation. It is not always practicable, nor indeed desira- 
ble, to isolate a patient for too long a period. Family considerations 
demand a return to the family circle as soon as possible. In these 
cases the course first mentioned is the most practicable. In cases 
which have exhibited a malignant septic form of the disease the 
author would advise prolonged isolation after convalescence,* for the 
safety of the other children. The urine of a scarlatinal case if there 
are even mild signs of nephritis, such as albumin and casts, is 



138 THE SPECIFIC INFECTIOUS DISEASES. 

believed to be infectious. A recent otitic discharge is thought to be 
capable of conveying the scarlatinal poison. 

The treatment of scarlet fever is largely symptomatic. In an 
ordinary mild case there is little to do but to regulate the diet, and 
keep the nose and throat freed from excess of secretion. The 
skin needs little care. During desquamation it is anointed once a 
day with a 1 per cent, salicylic acid or boric acid ointment. The 
urine should be examined daily, for even in the mildest cases severe 
nephritis is apt to intervene. Vigilance should not be relaxed 
until after the fourth week. The fever in simple cases needs only 
the mildest measures. We should remember that the tendency of 
the fever is to mount until the eruption is fully developed. It then 
naturally remits. Thus a temperature of 105° F. (40.5° C.) in an 
ordinary uncomplicated case may not last more than a few hours. 
In ordinary cases sponging with lukewarm water is efficacious. The 
aim is not so much to reduce the temperature as to support the 
nervous system and the heart. In private practice it is well not to 
resort at once to full baths simply because the temperature is above 
104° F. (40° C). The reverse is true with temperatures which are 
persistently high for days. In such cases the author resorts to full 
baths. The patient is placed in a bath at 100° F. (37.7° C.), and 
the water cooled to 85° F. (29.4° C). With children it is well 
not to resort to lower temperatures. This is especially true in the 
asthenic forms of sepsis. The patients fail to react after the bath, 
and seem weakened by the excessive cold. The patients remain in 
the bath about five minutes, and are then taken out. In cases in 
which the temperature mounts above 105° F. (40.5° C.) we may 
employ the pack at a temperature of 70° F. (21.1° C), with much 
benefit if the reaction is good. The trunk pack may be repeated 
every one or two hours. The baths above described may be given 
every four hours. While the patients are in the bath reaction 
may be promoted by mild friction. Patients with scarlet fever, espe- 
cially young children, do not bear baths below 75° F. (23.8° C.) 
well. The old theory that kidney complications are caused by cold 
baths is not proved. On the contrary, in uraemia Kussmaul lays 
much weight on the beneficial effects of cold packs where hot baths 
produce untoward symptoms (Baruch). 

Antipyretics are of little value in scarlet fever, and should not be 
used unless there is some special contraindication against hydro- 
therapy. Antipyretics of the coal-tar series especially, weaken the 
heart in the toxaemia which accompanies scarlet fever. 

Heart. — The heart is supported in septic cases with high tem- 
perature, in the same manner as in other diseases of a toxic 
nature. Alcohol (whiskey) is not given in mild cases. In consid- 
ering its administration the kidneys should be taken into account. 
We wait until the temperature remains persistently high. At the 



SCARLET FEVER. 139 

third or fourth day a constant temperature of 105° F. (40.5° C.) 
which refuses to abate with treatment calls for the employment of 
alcohol with other remedies. For a child of from two to five years 
half a drachm to a drachm of alcohol every three hours is a suffi- 
cient dose. Alcohol and digitalis are probably our best cardiac 
remedies. Caifeineand camphor may also be employed. Strychnine 
does not seem to do so well in cases in which there is an active 
myocarditis. 

Throat and Nose. — In inflammations of these passages we simply 
keep the parts sprayed with an alkaline solution in order to 
remove excessive secretion. In this way the patient is made com- 
fortable and the inflammation of the fauces kept within bounds. It 
is not always possible to spray the throats of the little ones. If 
there is nasal involvement, the passages may be kept clear by 
syringing with salt solution. Strong antiseptic solutions or solu- 
tions of sublimate or peroxide of hydrogen are of little use if 
not harmful. Antitoxin of diphtheria is employed if true Loffler 
diphtheria coexists. In the streptococcic or most common form 
of pseudomembranous inflammation we have no remedy which acts 
directly on the inflammation. Antistreptococcic serum has not given 
encouraging results. 

Lymph-nodes. — The lymph-nodes, especially in the region of the 
angle of the jaw, are, if swollen, treated with local cold applications. 
This frequently aifords much relief. Unless distinct fluctuation 
exists, we should avoid incision of the lymph-nodes of the neck. 
The author has seen these nodes incised at the beginning of the 
second week in septic cases, with very unsatisfactory results. Pus 
is not found in such cases, but only foci of necrosis, which are best 
left to nature until the patient regains strength. Later in the dis- 
ease such nodes may suppurate and need incision. 

Nephritis. — The treatment of nephritis is elsewhere described in 
detail. The lines of procedure are indicated here. Headache, vomit- 
ing, and convulsions are treated with hot baths, and by the con- 
tinuous irrigation of hot saline solution (Kemp) per rectum. The 
kidneys are apt to be aifected from the outset in malignant cases. 
In these cases the Kemp treatment with saline enemata is most suit- 
able. With young or intractable children the continuous irrigation 
of Kemp cannot be carried out. In these cases a high rectal enema 
of normal saline solution (Cantani) is given twice daily or more 
often if necessary. If general anasarca is present, the patient is 
given two warm baths daily ; or by wrapping him in a blanket 
which lias been moistened with hot water and then wrung dry we 
may facilitate diaphoresis with hot air. Digitalis in the form of 
infusion is the most efficient remedy, combined with moderate d<>-<- 
of potassium acetate, tartrate, or citrate. Milk is the exclusive diet. 
Complete suppression of urine, with blood and all the anatomical 



140 THE SPECIFIC INFECTIOUS DISEASES. 

elements of severe inflammation of the kidney, will sometimes be 
followed by an increased amount of urine. In such cases the treat- 
ment just indicated will not be efficacious. The heart must be sup- 
ported, and watch kept for ursemic symptoms. Opium should be 
employed with extreme caution — best not at all in convulsions; 
chloroform inhalations with chloral per rectum are preferable. Saline 
enemata at 108° F. (42.2° C), diuretin, and nitroglycerin are appli- 
cable in those cases in which there is suppression of urine. 

Otitis is sometimes first indicated by spontaneous perforation and 
purulent discharge. In other cases pain with a sharp rise of tem- 
perature will indicate inflammation of one or both ears. Para- 
centesis is best performed early, even if only slight redness of the 
drum is present. Later in the disease (fifth or sixth week) both 
ears may continue to discharge profusely, with an evening rise of 
temperature. In some cases the author has noted slight frontal 
headache and drowsiness toward evening. There may be only a 
slight redness over the mastoid of one or both ears. It is best not 
to temporize in such cases, but to advise opening the mastoid process 
to insure drainage and avoid sinus thrombosis or cerebral abscess. 

Complications in the lung, such as bronchopneumonia, are treated 
on general lines. We should in all cases be on the lookout for 
pleuritic effusion. Extensive effusions must be aspirated. In all 
forms of pleurisy, even if the amount of fluid is not large, but per- 
sists, with a rise and fall of temperature, we should introduce a 
needle to determine the nature of the fluid. Pus should be evacuated 
from the pleura in the manner directed in the chapter on Empyema. 

Joints. — Joint-affections are best treated by immobilizing the 
affected articulations. The patient should be kept quiet, and sodium 
salicylate in liberal doses administered. If this is ineffectual after 
a few days, the joints should be wrapped in cotton moistened with 
oil of wintergreen, and sodium bicarbonate given in very liberal 
doses (grain x (0.7) for a child of three or four years, four times 
daily). If synovitis occurs and the fever continues high, the joint 
should be aspirated under antiseptic precautions, in order to ascer- 
tain if pus is present. If this is the case, an incision with drainage 
is the proper remedy. 



ROTHELN. 

( German Measles ; Rubella ; Trousseau's Roseola. ) 

Epidemics of this disease have been described by Forney, 1784 ; 
Heim, 1812 ; Hildebrand, 1832 ; and in recent times by Thomas 
and Crozer Griffith. It is an acute infectious disease, contagious 
from person to person through the atmosphere, though not as highly 
so as measles. It may occur in the same person a number of times, 



ROTHELS. 141 

and may attack those who have had measles. All children exposed 
do not develop the disease. 

Age. — The youngest patient in the author's experience was seven 
weeks old. The affection may occur at any age. The author has 
met it in adults. It occurs with the same frequency in both sexes. 

Prodromal Period. — There is a prodromal period, during which 
there may be a slight suffusion of the eyes, with swelling of the con- 
junctival fold at the inner canthus of the eye. In two cases ob- 
served by the author the lymph-nodes behind the border of the 
sternomastoid muscle were observed to be enlarged six days before 
the appearance of the exanthema. There is no fever or constitu- 
tional disturbance. The period of incubation is placed by Thomas 
and Emminghaus at from fifteen to twenty days. Just prior to 
the eruption there are headache, nausea, and bronchial irritation 
(Forcheimer, Emminghaus). 

Exanthema. — The exanthema resembles that of measles so 
closely that at the outset it is common for physicians to mistake one 
for the other. It is also similar in that it is first noticed to ap- 
pear faintly around the alae nasi and on the upper lips. The exan- 
thema appears first on the face, at the temporal regions, and on 
the cheeks. It is in some cases preceded by an erythematous blush 
diffused over the whole face (Emminghaus), which disappears in a 
few hours, leaving the true exanthema (pre-exanthematic erythema). 
The exanthema is papular, of a deep rose-red color, and distinctly 
arranged in crescentic outlines. This arrangement of the papules 
in circles and half circles can be made out where the eruption is 
spreading. On the face and neck it gives place to the blotchy ap- 
pearance characteristic of measles. As a rule, the eruption remains 
discrete. (Edema is rarely present. The papules have been de- 
scribed as of two varieties — one the size of those in measles, and 
the other punctate (Thomas). The punctate papules have been 
seen by the author on the upper part of the chest, where the erup- 
tion is confluent. They are likely to be mistaken in these cases 
for the exanthema of scarlet fever. In some cases of Thomas and 
of the author the punctate papules only were present over the Avhole 
trunk. There is an absence of the intense dermatitis seen in scarlet 
fever, and the individual roseolar spots have the outline above 
referred to. The exanthema, while fading on the face and chest, 
spreads slowly on the extremities. The exanthema remains dis- 
crete where it is spreading. It remains at its efflorescence on the 
face and trunk from a few hours to a day, when it begins to fade 
first from the face, and then from the trunk. A patient may pre- 
sent a perfectly normal skin twenty-four hours after the appear- 
ance of the eruption. Evidences of the eruption may remain on 
the trunk and skin for two or three days. The skin then may pre- 
sent bluish or brownish crescentic spots in place of the original 



142 



THE SPECIFIC INFECTIOUS DISEASES. 



exanthema, similar to what is seen in simple erythema. Four days 
alter the eruption has appeared the skin in most cases will have 
a normal hue. There is no pigmentation or discoloration as in 
measles. 

Desquamation. — Desquamation is not always apparent. It is 
possible in exceptional cases to see a very slight desquamation only 
at the upper part of the thorax or inner portion of the thighs. 

The Eruption on the Mucous Membranes. — In rotheln the 
eruption on the mucous membranes does not resemble the exanthema 
of the skin. There is an eruption in the mouth, but it is not char- 
acteristic. There is a mild injection of the conjunctiva, a redness 
of the fauces, and perhaps a slight cough. Coryza, photophobia, 
and bronchitis are absent. The mild angina and the injection of 
the conjunctiva resemble what is seen in la grippe. Thomas and 

























Fig. 


33. 




























DAY OF 

MONTH 


1 


2 


3 


4 


DAY 


A.M. 


P.M. 


A.M. 


P.M. 


A.M. 


P.M. 


A.M. 


101° 

<r 

I 

if 

-100 

a. 
E 
111 

99° 
















































































^ 
























































o 
























































1U 
























































o 
























































111 










































_y 


m 












=> 










































7 


< 












u- 










































' 


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o 








































/ 




o 












o 








































/ 




z 












H 












































p 






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ii; 








\ 




W 












































ill 










































































\ 


























































S 


























































N^ 








^ 


















































s 


s* 




































































































































PULSE 


108 


116 


120 


120 


120 


108 


104 


RES P. 


24 


24 


24 


24 


20 


22 


20 



Temperature-curve of a case of rotheln in a boy six years of age. Observed from 

the outset. 

Emminghaus have described an irregular, spotted, streaked appear- 
ance, with small grayish miliary vesicles, on the soft and the hard 
palate. Gerhardt has described a spotted hemorrhagic eruption on 
the palate, and Forcheimer an irregular macular rose-red eruption 
on the soft palate. None of these is constant or characteristic of 
rotheln, but all are found in other affections. The buccal mucous 
membrane, however, is absolutely free from eruption of any kind, and 
in this fact we have a valuable diagnostic distinction between this 
disease and measles. In a small percentage of cases a few red stel- 
late spots on the buccal mucous membrane have been seen by the 
author. In no case, however, was the measles spot with its bluish- 
white central speck present. 

The temperature may at the outset be 99.8° F. (37.5° C.) in the 
rectum, and continue at this point throughout the disease. It may 



MEASLES. 143 

be 102° F. (38. 8 C C), rarely higher. The temperature is highest 
at the outset when the exanthema appears on the face (Fig. 33). 
It falls rapidly within a few hours by a sort of crisis. Meanwhile 
the eruption may spread to the lower extremities. 

Lymph-nodes. — The author has observed a number of cases 
with especial reference to the lymph-nodes. Before the appearance 
of the eruption the nodes behind the sternomastoid and angles 
of the jaw may be enlarged. At the time of appearance of the 
exanthema the nodes of the axilla, bicipital groove, and groin become 
enlarged to the size of a bean or larger. The nodes may remain 
enlarged for weeks after the eruption has disappeared. 

The spleen is not enlarged. 

The Genitals. — In one case the injection of the vulvar mucous 
membrane caused temporary dysuria. 

Complications. — Rotheln is such a mild disease that complica- 
tions are rare. 

Prognosis. — The patients recover rapidly. 

Diagnosis. — The diagnosis of rotheln should not present any dif- 
ficulties. It is most likely to be confounded with measles, scarlet 
fever, and erythematous eruptions. 

The symptoms are much milder, and there is an absence of the 
specific buccal enanthema of measles. Measles does not, as a rule, 
present simultaneous lymph-node enlargements all over the body, 
such as are seen in rotheln. 

Scarlet fever presents a severe dermatitis, which is absent in 
rotheln. There is a marked angina of a progressive type, with high 
temperature. The general enlargement of lymph-nodes is not so 
useful a sign, since in scarlet fever the lymph-nodes of the neck may 
be enlarged at the angle of the jaw, or those in the axillae and in the 
groin may enlarge as the eruption develops. In scarlet fever there is 
a characteristic desquamation. 

Erythematous eruptions of the small papular type may resemble 
rotheln, but the characteristic crescentic outline of the rotheln roseola 
is absent. 

Treatment. — Isolation need not be rigid. Children are kept 
indoors in summer until the eruption has disappeared and the tem- 
perature is normal. In the winter months the patients are kept 
indoors one week from the onset of the disease. The angina rarely 
requires treatment. 

MEASLES. 

(Rubeola ; MorbilH.) 

Measles is an acute infectious disease distinguished by a char- 
acteristic eruption on the mucous membranes and skin. It is 
highly contagious, and is propagated through the atmosphere. The 



144 THE SPECIFIC INFECTIOUS DISEASES. 

specific agent has not been isolated. Most people are susceptible to 
measles, and suffer from at least one attack. Infants up to the 
age of five months are not so susceptible as at a later period. 
Newborn infants have been infected by the mother, and the foetus has 
been infected in utero. Only the firstborn is believed by Thomas 
to be immune for the period mentioned. The disease is very infre- 
quent during the first year of life. Bartels calculates the occur- 
rence at this time at 5 per cent, of the total number of cases. 
The author has seen measles in infants under five months of age. 
Measles is most frequent between the age of one and five years 
(Bartels, Henoch). It is prevalent in all countries of the globe ; 
climate or meteorological conditions seem to have no influence 
upon its prevalence either endemically or epidemically. 

Measles has a well-defined period of incubation, varying from 
thirteen to fifteen days (Van Panum). In calculating this period 
we include the time which elapses from exposure to the appearance 
of the eruption on the body. It will be seen later that this period 
includes the period of incubation proper, in which absolutely no 
symptoms, not even fever or malaise, are apparent, and the period 
of the enanthema on the mucous membrane. The enanthema, 
which may be accompanied by coryza of mild or severe type, may 
appear from the ninth to the tenth day after exposure, and lasts 
from three to five days. Thus while the coryza may be postponed 
several days or the enanthema may be present for a variable period, 
the two periods together have a duration of from thirteen to fifteen 
days. I have seen the enanthema fully five days before the exan- 
thema, and have seen cases of this kind without any manifestations 
of coryza to signalize the onset of the disease. It is erroneous, 
therefore, to calculate the period of incubation from the exposure 
to the onset of coryza, as the latter is variable as to the time of 
its appearance. 

One attack protects the individual from subsequent attacks. 
Authentic cases of two attacks in the same individual have recently 
been recorded. By this is not meant a recrudescence of the ex- 
anthema after it has once faded. This is also known to occur 
(Jurgensen). Experiments have proved that measles is highly con- 
tagious in the catarrhal stage. Inoculations w T ith the blood (Home) 
and nasal secretions (Mayr) have given positive results. The period 
of greatest contagion extends through the period of the exanthema. 
It diminishes as the exanthema fades, and is thought to disappear 
gradually during the period of desquamation. Thus though more 
general in its power to infect, the poison of measles has a shorter 
period of life than that of scarlet fever. The poison of the latter 
disease may retain its power of infection months after the disease 
has run its course. From what has been said, it will be under- 
stood that the infection in measles takes place in the vast majority 



MEASLES. 145 

of cases in the stage of the enanthema (incubation). At this time 
there may be no coryza. 

Infection occurs during the stage of desquamation (Baginsky). 
If ordinary caution is exercised, it is doubtful whether measles is 
ever carried by a healthy individual to a third person as scarlet 
fever is. Baginsky records an epidemic caused in this manner. The 
poison does not adhere to articles of furniture and wearing apparel 
with the same tenacity as in scarlet fever. 



The Ordinary Type of the Disease. 

The ordinary simple type of measles is that which runs its course 
without any complications or sequelae. There is a prodromal period, 
which includes the period of incubation before the appearance of the 
enanthema on the mucous membrane of the mouth. During this 
period it is well established that there are no clinical symptoms 
whatever — neither fever nor malaise. At the time of the appear- 
ance of the enanthema on the mucous membrane the patient begins 
to feel slightly ill. The symptoms may be only a headache or a 
slight disturbance of the stomach. The author has noted in some 
cases a rise of a degree or more in temperature toward evening. 
There are at this time slight injection of the eyes and general las- 
situde. Coryza is not pronounced. The patient during the first 
days of the enanthema, and by this is meant forty-eight to seventy- 
two hours before the appearance of the exanthema on the skin, pre- 
sents few signs of illness. If, guided by the very faint redness 
at the inner canthus of the eyes, we look into the mouth, a few 
spots of a very characteristic eruption are seen on the buccal mucous 
membrane. This eruption is pathognomonic of the invasion of 
measles, and will be later described as the enanthema. After fortv- 
eight to seventy-two hours, and in some cases a longer period, there 
are coryza, cough, and conjunctivitis. There is a slight febrile 
movement, varying in intensity in different eases. The exanthema 
now appears, and is first noticed at the temporal region of the face 
and the ala? nasi as a macular rose-red spotted eruption, which 
becomes papular later in the course of the disease. The face and 
scalp are now fully covered by the rose-red irregularly shaped 
papules, which next appear in rapid succession on the back of the 
hands, forearms, anterior part of the trunk, back, and lower extremi- 
ties. This order of the appearance of the exanthema is not always 
maintained, in some cases, as pointed out by Rehn, and verified 
by the author, the eruption may first appear on the back. It is, 
therefore, advisable to examine the patient in a nude state. 

The eruptive stag • of measles generally lasts three or four days, 
during which the patient has an exacerbation of all the symptoms 
of the stage of invasion. There are intens< photophobia, active; 

10 



146 THE SPECIFIC INFECTIOUS DISEASES. 

coryza, and a croupy cough as a result of the invasion of the laryn- 
geal mucous membrane by the enanthema. The bronchi are also 
affected, and there are symptoms of acute bronchitis. Even very 
mild cases of measles show laryngeal and bronchial involvement. 
At this stage the exanthema on the skin is general and profuse, 
and in places confluent. The patches of healthy skin are crescentic, 
owing to the peculiar conformation of the papules. In some mild 
cases the rash may be very diffuse, but in others discrete. In the 
mildest forms of measles the rash closely resembles in the latter 
respect that seen in rotheln. 

The fever reaches its height when the eruption on the skin is fully 
developed. If the mucous membrane is inspected at the height of 
the skin eruption, it will be seen that the enanthema becomes 
diffuse before the eruption of the skin is fully developed. The 
mucous membrane of the mouth is diffusely inflamed and studded 
with bluish-white specks which rapidly disappear or desquamate. 
The eruption on the skin persists for three or four days and then 
begins to fade. With disappearance of the eruption the general 
symptoms abate. The fever remits, and the temperature becomes 
normal by gradual morning remissions. The coryza, cough, and 
photophobia lessen, and the patient passes into the convalescent 
period. Desquamation begins when the pinkish hue of the eruption 
has disappeared. This stage continues until the last vestige of pig- 
mented spots on the skin has disappeared. As a rule, it is com- 
pleted two weeks after the exanthema has made its appearance. 
Desquamation is never absent in measles (Crozer Griffith), but it 
may be difficult to detect its presence. The epithelium is shed in the 
form of branny scales. Desquamation is best seen on the anterior 
part of the chest, shoulders, and inner surface of the thighs. In 
uncomplicated cases it is not attended by constitutional symptoms. 

The Temperature. — Measles presents no characteristic fever-curve. 
The invasion is rarely signalized by a chill. There may be a slight 
sensation of chilliness. The prodromal period before the appear- 
ance of the enanthema is not marked by fever. The period of the 
enanthema presents a slight temperature with morning remissions to 
normal. When the eruption appears on the skin the fever increases, 
and reaches its height after thirty-six hours, at the time of the full 
development of the eruption. The temperature continues high with 
morning or evening remissions for from one and a half to tAvo and 
a half days, and then subsides, and disappears in from twenty-four 
to thirty-six hours after desquamation has set in. The temperature 
may reach 104°-105.8° F. (40°-41° C.) without complications. 
During the stage of desquamation the temperature is not elevated 
unless complication exists in 'the lung or elsewhere (Fig. 34). 

I have sketched the type of disease which is not complicated by 
serious affection of the viscera and which has no sequelae. On 



MEASLES. 



147 



account of variations from the simple type just described, measles 
is one of the most dreaded diseases of infancy and childhood. 

In fatal cases occurring during the first two years of life the lung 
is generally involved (Henoch). The appearance of the eruption is 
ushered in with a convulsive seizure or a chill. The pneumonia 
appears as the eruption reaches its height, and within two weeks 
either proves fatal or else leaves the patient weakened or the subject 
of an empyema. The infection of the kidneys may be so severe as 
to prove speedily fatal, or there may be severe mastoid disease. On 
the other hand, there are cases of measles of a type so mild as to 
cause little constitutional disturbance. The fever is very mild and 
evanescent, and present only at the outbreak of the eruption, and 
even at this stage may be so slight as to escape notice. Jiirgensen 
records measles without fever. 



Fig. 34. 



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P'JLSE 


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Uncomplicated measles in a boy of five years. 

The Enanthema. — This is the eruption which appears on the 
mucous membrane of the mouth. It differs from the exanthema 
in respect to location. The enanthema appears in the mouth from 
three to five days before the appearance of the exanthema. It is 
accompanied by redness of the pharynx, and of the anterior and 
posterior pillars of the fauces. The soft palate is studded with 
irregularly shaped rose-colored spots or streaks. The spots on the 
hard palate present small whitish, punctate, miliary vesicles. These 
spots are also found on the otherwise normally colored mucous 
membrane of the cheeks and on that opposite the gums of the upper 
and lower molar teeth. They have been described by Flindt in 
these localities and on the palpebral conjunctiva. Filatow has de- 
scribed a desquamation of the epithelium of the mucous membrane 
of the lips and cheeks, in the form of minute whitish shreds (Slawyk). 
A complete series of studies of the enanthema of measles has been 



148 THE SPECIFIC INFECTIOUS DISEASES. 

made, and there can, therefore, be no doubt of its existence. In 
1896 I published a study of the enanthema on the buccal mucous 
membrane, and on the inner surface of the lips. In this study 
I showed that the enanthema on the hard and soft palate so fre- 
quently described since the publication of Rehn was not peculiar 
to measles. The spots of rose-colored papules or streaks with the 
superimposed miliary vesicles are found in rotheln, scarlet fever, and 
some cases of simple angina. The eruption on the buccal mucous 
membrane alone, however, preceding the appearance of the exanthema 
on the skin by a period of from three to five days, is characteristic 
of the invasion of measles. It is pathognomonic of the disease, and 
occurs in no other known conditions. It is almost invariably pres- 
ent, observations having shown it to be absent in only a very small 
percentage of cases. 

On looking at the mucous membrane lining the cheeks (buccal) 
in strong sunlight, a very characteristic eruption of irregular stel- 
late or round rose-colored spots is seen. In the centre of each spot 
there is a bluish-white speck. This appearance of a bluish-white 
speck on a rose-colored background is pathognomonic of the begin- 
ning of measles. The speck is sometimes so minute that strong 
sunlight is necessary to render it visible. The number of specks 
at the outset may be less than half a dozen. In a short time they 
become more numerous, and the rose-colored spots become conflu- 
ent, so that there are diffusely red patches of buccal mucous mem- 
brane studded with bluish-white specks. The specks rarely or 
never become confluent ; their color does not resemble that of sprue, 
nor are they as coarse as sprue accumulations. They are seen on 
the inner surface of the lips, and are sometimes well marked on 
the buccal mucous membrane adjacent to the gums of the upper 
molar teeth. If the finger is passed over the mucous membrane, 
they are felt to be raised and firmly adherent. They can be 
rubbed off by force or picked off with forceps. As the exanthema 
spreads, the enanthema of the buccal mucous membrane becomes 
diffuse. When the exanthema is at its height and during efflo- 
rescence the eruption on the mucous membrane begins to lose its 
characteristics. The bluish-white specks are washed away by the 
buccal secretions and leave the mucous membrane diffusely red- 
dened and raw. 

By referring to the temperature-curve, it will be seen that the 
appearance of the enanthema is accompanied before the outbreak of 
the skin eruption by fever of a low type. 

The exanthema of measles is a characteristic eruption of rose- 
colored or purple-colored papules, varying in diameter from 1 mil- 
limetre to 1 centimetre, the average diameter being 2 millimetres. 
They are irregularly circular, or longer in one diameter than another, 
or shaped like a half-moon. They arrange themselves crescentically. 



PLATE VII. 



Fig. I. 



Fig. II. 





Fig. III. 



Fig. IV. 





The Pathognomonic Sign of Measles (Koplik's Spots). 



Fig. i. — The discrete measles spots on the huccal mucous membrane, showing the isolated rose-red 
spot, with the minute bluish-white centre, on the normally colored mucous membrane. 

Fig. 2. — Shows the increased eruption of spots on the mucous membrane of the cheeks ; patches of pale 
pink interspersed among rose-red areas, the latter showing numerous pale bluish-white spots. 

Fig. 3.— The appearance of the buccal mucous membrane when the measles spots coalesce and give a 
diffuse redness, with myriads of bluish-white specks. The exanthema is at this time fully developed. 

Fig. 4. — Aphthous stomatitis sometimes mistaken for measles spots. Mucous membrane normal in 
color. Minute _>v//ozi/ points are surrounded by a red area. Always discrete. 



MEASLES. 149 

They are at first discrete, but soon become confluent, so that large 
areas of skin are covered. Here and there arc areas of normally 
colored skin. The discrete papules have a distinctly crescentic 
arrangement. This is seen on the thorax and thighs. As a rule, 
the whole face is covered with the eruption, and the skin swollen. 
The eruption spreads from the face and head to the back of the 
neck, throat, upper part of the back, chest, and back of the hands 
and arms. The lower extremities become affected, as well as the 
palms of the hands and soles of the feet. As a rule, the eruption 
on the skin is papular ; the papules may show at their summit miliary 
vesicles. They may become confluent and form patches. Hemor- 
rhages may occur in and around the papules (Morbilli hemor- 
rhagica). In these cases petechia? occur in the course of the exan- 
thema, and persist into the period of desquamation. They should 
not be confounded with petechial eruptions or purpura, which may 
appear after the exanthema has run its course. The exanthema in 
weakly children may be limited in its distribution and not charac- 
teristic. Henoch believes that many cases in which the exanthema 
does not develop in sequence, take a subsequent course which may 
be severe. If therefore the exanthema should first appear on the 
back, instead of the face, and spread thence, complications may be 
expected. Although complications occur with eruptions which are 
diffuse and very general, the severity of the eruption is no index as 
to the severity of the disease. 

When the exanthema fades, it leaves the skin studded with dirty 
brownish-colored spots, which have the arrangement of the original 
exanthema. These pigmented areas gradually fade, and when 
desquamation is complete they disappear. 

Measles may run its course without the appearance of the exan- 
thema on the face. It may be ill-defined and limited to certain 
parts of the body. It may develop in full intensity and then sud- 
denly fade within a few hours. This occurs in cases in which 
severe disturbances of the circulation alter the distribution of blood 
in the skin. In these cases there may be a complication of the 
lungs or heart, but the fading of the exanthema is not, as is thought 
by the laity, primarily the cause of any affection of the internal 
organs. 

The Nose, Pharynx, and Larynx. — In very young infants severe 
inflammation of the mucous membrane of the nose and nasopharynx 
may lead to difficulties not only in breathing, but also in feeding. 
In these cases membrane rarely develops. If it does appear, it takes 
the form of a pseudomembranous rhinitis, generally of a diphtheroid 
streptococcic nature. Its course then may be subacute. The larynx 
is sometimes severely affected, so that at the height of the exan- 
thema the patient is troubled with a harassing, croupy cough. In 
some cases the patient becomes almost aphonic. If there is no 



150 THE SPECIFIC INFECTIOUS DISEASES. 

obstruction to the breathing, this symptom, which causes great con- 
cern, disappears. The larynx may present a pseudomembranous 
affection of a streptococcic nature. Gerhardt has shown that ulcer- 
ation of the posterior laryngeal wall may ensue from traumatism to 
the larynx as a result of repeated fits of coughing. If these ulcera- 
tions cause swelling of the mucous membrane, obstruction to respira- 
tion may result. The bronchitis which is always present in such 
cases may cause obstruction of the finer bronchi. On account of inef- 
ficient respiratory effort atelectasis and pneumonia may result, with 
fatal issue. 

Diphtheria may complicate measles. It may precede the erup- 
tion, or may develop at any time during the attack. In all such 
cases the patient has been exposed to a double infection. In one 
case in the author's hospital service the patient had recovered from 
diphtheria two weeks previous to the attack of measles. Three 
days after the appearance of the exanthema the conjunctiva became 
covered with true diphtheritic membrane. The larynx then became 
involved, and stenosis set in within twenty-four hours after the 
appearance cf the membrane on the conjunctiva. The exanthema 
in these cases is likely to fade rapidly or become hemorrhagic. 
Cases of diphtheria complicated with measles are rapidly fatal, since 
the trachea and bronchi become involved. Fatal pneumonia super- 
venes. On the other hand, the author has seen a croupy cough with 
dyspnoea, set in three weeks after convalescence from measles. 
Diphtheria bacilli were found in the pharynx, and yet recovery 
took place. In this case no pseudomembrane on the pharynx was 
visible. It is not always possible to decide in a given case whether 
there is a simple swelling of the mucous membrane of the larynx 
or a pseudomembranous process. In cases with severe laryngeal 
symptoms, if no membrane is visible, a culture of the secretions of 
the pharynx should be made. The temperature-curve does not aid 
us. Diphtheria may run its course with a low or a high tempera- 
ture. The pulse is of little assistance in making a diagnosis. There 
is nothing in the nature of measles which predisposes toward diph- 
theritic infection. 

During convalescence persistent hoarseness or aphonia is not 
infrequently seen without other disturbances. The voice gradually 
returns to the normal. 1 

Bronchitis ; Bronchopneumonia ; Atelectasis. — A very serious com- 
plication of measles is bronchitis, which may involve the capillary 
bronchi, causing atelectasis and bronchopneumonia. In the stage 
of efflorescence the bronchitis at times becomes severe. There are 

1 Prudden and Northrup, in a paper on diphtheria with fatal pneumonia, 
record 3 cnses of fatal diphtheria complicating measles. The diphtheria and subse- 
quent pneumonia were of the streptococcus variety. The 3 cases formed part of a 
series of 17 cases of streptococcus diphtheria followed by pneumonia. 



MEASLES. 151 

found on auscultation fine crepitant rales in addition to the very- 
coarse mucous and sonorous rales. At the end of inspiration a 
fine crepitation is heard, similar to that present at the beginning 
of pneumonia. There is also subcrepitation at the close of expi- 
ration. In these cases the constitutional symptoms are severe, 
if largo areas of lung are involved. The dyspnoea is extreme. 
Although cyanosis may be present, no areas of consolidation are 
detected on physical examination. It is reasonable to infer that 
in all the cases of severe inflammation of the smaller bronchi, areas 
of bronchopneumonia exist. Auscultation may reveal areas of lung 
in which the air enters imperfectly. An attack of coughing will 
open up the bronchi, when air again enters these areas (atelectasis). 
In young infants and children this form of bronchitis is a serious 
complication. As a rule, it leads to bronchopneumonia. 

The pneumonia which complicates measles, either in the eruptive 
stage or in the desquamative period, is anatomically usually of the 
bronchopneumonic type, although the lobar form may occur. The 
pneumonia is caused by an invasion of the lung tissue by strep- 
tococci from the bronchi. A bronchopneumonia may at first be 
difficult of detection. As a rule, however, it involves a lobe of 
the lung in a short time. The lower portions of the lung behind 
are usually first involved, although the upper lobes or middle lobe 
may in exceptional cases be first involved. When consolidation 
takes place, the area of lung involved may be as extensive as in 
lobar pneumonia. A pneumonic process should be suspected if 
the temperature in the stage of desquamation does not fall to the 
normal. There is a distinct rise of temperature which varies in 
intensity, and remits in the morning to become higher in the even- 
ing. The cough becomes troublesome, and there is also dyspnoea. 
In such cases the temperature alone cannot be relied upon for a 
diagnosis. A careful physical examination will be of assistance. 
Under two years of age this form of bronchopneumonia is very 
fatal. As a rule, pneumonia complicating measles terminates, if not 
in immediate recovery, in a bronchopneumonia which persists for 
weeks. The temperature may fall almost to the normal in the morn- 
ing and in the evening rise a degree or more. In addition to the 
bronchopneumonia there may be pleurisy, with thickening of the 
pleura and purulent exudate. In some cases the upper lobe of the 
lung shows signs of unresolved pneumonia for weeks. Emaciation 
is progressive. All of these cases are not necessarily tuberculous. 
A tuberculous process may be engrafted on a non-tubercnlous 
bronchopneumonia at any time by infection with tubercle bacilli. 
In measles there scorns to be a predisposition to invasion of the 
lung by tubercle bacilli through the catarrhal and inflamed mucous 
membrane of the bronchi. Wo can reasonably hope for recovery in 
many of those cases of simple chronic bronchopneumonia. If tuber- 



152 



THE SPECIFIC INFECTIOUS DISEASES. 



culous glands, which have been dormant before the invasion of 
measles exist, they form focal points for the development of tuber- 
culosis of the lungs or meninges. Such cases are fatal. Autopsy 
will reveal recent lesions alongside of old tuberculous foci. 

The frequency of infection with tuberculosis varies in different 
localities. In some epidemics it occurs in 5 per cent, of the cases ; 
in others, 16 per cent, or more are affected (Bartels, Jurgensen). 

The Heart. — The endocardium is rarely affected in measles. If 
endocarditis does occur, it is usually an intercurrent affection in a 
rheumatic subject. Fig. 35 shows a temperature-curve from a case in 
which rheumatism preceded an attack of measles, and which in turn 
was followed by endocarditis. Myocarditis may be found in fatal 
cases of bronchopneumonia. In bronchopneumonia complicated 
with pleurisy, pericarditis may also be present (Baginsky). 





















Fig. 35. 






















DATE 


8 


9 


10 


11 


12 


13 


14 


15 


16 


Fel 
17 


18 


iry 
19 


20 


21 


22 


23 


24 


25 


26 


27 


28 


105 

104 

~ 103° 
¥ o 
5 102 

- 101° 

| 100° 

■" 99° 
98° 

97° 
















































M 


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PULSE 


102 


118 


116 


124 


132 


124 


134 


140 


140 


132 


140 


146 


136 


140 


140 


128 


142 


140 


130 


128 


130 


RESP. 


24 


32 


34 


42 


60 


62 


56 


62 


60 


60 


54 


50 


70 


68 


60 


56 


54 


50 


52 


60 


50 



Measles complicated with endocarditis in a boy six years of age. 



The Intestines. — In some epidemics diarrhoea is a frequent com- 
plication. The movements are numerous, and watery in character. 
When the large intestine is involved the stools contain blood and 
mucus, and tenesmus is present. The season of the year influences 
the intensity of the infection. In the w T arm months the diarrhoea 
may be of a severe type. In cases recorded by Henoch and Thomas, 
autopsy showed enlarged Peyer's patches and solitary follicles resem- 
bling those seen in typhoid fever. No cases of ulceration have been 
recorded. Jurgensen is inclined to consider the diarrhoea a result of 
infection of the intestinal mucous membrane. The enanthema appears 
in this locality early in the disease. 

The Kidneys. — In many cases of measles, albumin and a few 
hyaline and epithelial casts are present in the urine. They are the 
result of a parenchymatous inflammation of the kidney, due to the 
poison of the disease. A true nephritis, such as is common in 
scarlet fever, is rarely seen. Nephritis is apt to occur in the severe 



MEASLES. 153 

oases complicated with bronchopneumonia. There may then be 
marked albuminuria, blood, and casts of all kinds in the urine, with 
suppression. On the other hand, nephritis in the stage of desqua- 
mation is rare. There is always in such cases suspicion that an 
infection coincident with scarlet fever may have been overlooked 
(Henoch). If diphtheria complicates measles, nephritis is likely to 
be present. 

The Bones and Joints. — The author has seen osteomyelitis with 
suppuration of the joints follow measles. Streptococci w r ere found 
in the pus. In one case bronchopneumonia was an earlier compli- 
cation. These cases are rare. 

Lymph-nodes. — If the inflammation of the throat is severe, the 
lymph-nodes at the angle of the jaw and underneath the body of the 
jaw may be enlarged. Rarely, however, is the adenitis as severe as 
in scarlet fever. The glands or nodes in the axillae, bicipital groove, 
over the internal condyle of the elbow-joint, and in the groin may be 
enlarged to the same extent as in rotheln, as a result of the processes 
taking place in the skin. Severe infection of the gut may cause 
swelling of the mesenteric lymph-nodes, which, if not tuberculous, 
will retrograde after the disease has run its course. 

The Blood. — Renaud has recently described a condition of leuco- 
eytosis in the stage of incubation. This reaches its maximum just 
before the appearance of the exanthema, and diminishes as it fades. 

The Nervous System. — It is rare to see convulsions usher in an 
attack of measles, even of a severe type. In anomalous forms of 
the disease complicated with pneumonia there maybe cerebral symp- 
toms similar to those seen in the latter affection. There may in 
some cases be a complicating cerebrospinal meningitis with purulent 
exudate. If tuberculosis is present, the meninges may be attacked, 
as in any tuberculous infection. French Avriters have observed 
neuritis following measles. 

The Eyes. — Following severe cases of measles, photophobia, spasm 
of the orbicularis, inflammation of the lachrymal duct, conjunctivitis, 
ulcerations of the cornea, and amaurosis may result. Hence, even 
in mild forms of the disease the eyes should be frequently inspected 
(Eversbusch). 

The Genitals. — The author has seen dysuria in cases in which the 
enanthema affected the mucous membrane of the vulva in girls. 
Henoch records cases of gangrene (noma) of th? genital organs. 

The Mouth. — Inasmuch as the mucous membrane of the mouth 
is the seat of an active eruption, stomatitis is likely to be present, 
especially if through carelessness or traumatism the mucous mem- 
brane has become infected with bacteria from without. In such 
cases aphtha? may result. Children in unhygienic surroundings 
are likely to develop noma of the cheek if exposed to the infection. 

Pertussis as a complication of measles is occasionally found. As 



154 THE SPECIFIC INFECTIOUS DISEASES. 

in diphtheritic infection, there must have been exposure to the con- 
tagion of both pertussis and measles, since etiologically the diseases 
have nothing in common. The danger in the coincident occurrence 
of measles and pertussis is that bronchopneumonia is likely to 
develop, and prove a serious if not fatal complication. 

The Ear. — The external structures of the ear may be affected by 
oedema and swelling. The external auditory canal may become the 
seat of painful swelling and diffuse inflammation. Gangrene of the 
pinna has been noted (Nottingham, Bourdillot). The most common 
affection of the ear is otitis media catarrhalis. Of 33 cases of 
severe complicated measles, Tobeitz found otitis of this variety in 
16. The frequency of otitis varies with different epidemics. The 
otitis makes its appearance in the period between the seventh and 
the twenty-sixth day following the development of the exanthema. 
Of 22 fatal cases of measles, otitis was found in 19, only 7 of which 
presented symptoms during life. The great majority of cases of 
otitis give no pronounced symptoms and end in resolution. These 
mild cases are the result of the action through the blood of the 
measles poison on the ear structures (hematogenic). The severe 
cases follow a mixed infection through the pharynx and Eustachian 
tube. In the pus of acute or chronic otitis, with or without inflam- 
mation of the mastoid, the streptococcus, Staphylococcus pyogenes, 
and pyogenic diplococci have been found. The general course of 
otitis is not so severe as that of scarlet fever. In some epidemics 
the severe and fatal cases are more common than in others. 

Sequelae. — Any of the complications named above may pursue 
a chronic course. In this sense only are they sequelae. Chronic 
blepharitis, blennorrhoea, keratitis, otitis, catarrhal inflammation 
or ulceration with stenosis of the larynx, septic retropharyngeal 
abscess, and chronic bronchopneumonia may persist for weeks or 
months. 

The prognosis in measles varies with the virulence of the epi- 
demic, the resistance of the individual, and the age of the patient. 
It is certain that the idea prevalent among the laity, that measles 
is a comparatively mild affection, is incorrect. In the cases treated 
in both dispensary and private practice, and at all periods of infancy 
and childhood, the mortality is 8 per cent. (Breyer). The mortality 
is greatest during the first year of life, and may vary in different 
epidemics from 10 to 40 per cent. The lowest mortality seems to be 
between the fifth and eighth years — 6 per cent. (Baginsky). Hos- 
pital statistics are of little value to the general practitioner, as the 
class of cases treated in these institutions give a high mortality- 
rate. The mortality in hospitals may be as high as 30 to 35 per 
cent. (Henoch, Furbringer). 

The diagnosis will in most cases present few difficulties if the 
physician follows a fixed routine in the examination of the patient. 



MEASLES. 155 

The mode of onset, the coryza, the enanthema of the buccal mucous 
membrane, ami the skin eruption are characteristic. If the physician 
will examine the inner surface of the cheeks and the buccal mucous 
membrane in every seemingly slight indisposition of children, he 
will in certain cases be able to predict an attack of measles far in 
advance of the appearance of the exanthema. Iu some cases the 
enanthema appears on the buccal mucous membrane before coryza is 
present. The inspection of the buccal mucous membrane thus 
becomes important as a prophylactic measure. Strong sunlight is 
essential for thorough inspection. Although the bluish-white spots 
on the rose-red background may sometimes be seeu by artificial light, 
especially electric light, a diagnosis of measles should never be made 
at night. Casss of influenza closely resemble measles at the outset. 
These present the injected conjunctivae, cough, and rose-colored 
spots on the soft and the hard palate seen in measles. In la grippe, 
however, the buccal mucous membrane is pale and presents abso- 
lutely no eruption. In one of the early grippe epidemics in New 
York the children showed an ill-defined roseolar eruption on the 
surface, but the buccal eruption was never present. 

Rotheln iu some cases resembles mild measles so closely that the 
author has often questioned whether so-called cases of mild measles 
without rise of temperature, described by authors, were not cases of 
rotheln. The difficulty in differentiation is increased if measles is 
prevalent at the same time. The absence of the buccal eruption is a 
crucial test. Schmid has also laid stress on this point. In some 
rare cases of rotheln there may be seen an isolated rose-red spot 
here and there on the buccal mucous membrane, but the bluish- 
white speck in the centre of these spots is never seen as in measles. 

Scarlet fever may at times closely resemble measles, especially 
in those forms in which the eruption on the face is evanescent. In 
scarlet fever the buccal mucous membrane has a normal hue. 
The author has seen scarlet fever complicated with measles. In 
these cases the scarlet eruption appeared first. Within two or three 
days there was a general recrudescence of the exanthema, with the 
appearance all over the body of a roseola (the scarlet rash had 
faded somewhat), coryza, and the buccal eruption. In other cases 
the scarlet fever eruption on the back of the hands and forearms 
assumes the blotchy, papular roseolar form of the exanthema of 
measles. The author lias seen a case of this kind in which an expert 
entertained the possibility of rotheln or measles. The buccal enan- 
thema was absent. The subsequent course of the case proved the 
diagnosis of scarlet fever to be correct. 

The roseola of typhoid is sometimes so abundant as to mislead 
the physician into mistaking it for the eruption of measles. Measles 
complicating typhoid at the end of the second week has come under 
the author's notice. In this case the buccal eruption was profuse. 



156 THE SPECIFIC INFECTIOUS DISEASES. 

Antitoxin and drug eruptions may simulate a measles eruption, 
but the buccal mucous membrane never presents the enanthema. 

The roseola of syphilis frequently resembles that of measles so 
closely as to cause uncertainty in the diagnosis. Here the conjunc- 
tivae may be injected, and there may be a slight febrile disturbance 
(Sobel). The buccal mucous membrane is pale, and shows no erup- 
tion resembling that seen in measles. 

The diagnosis of measles thus resolves itself into a recognition 
of the disease before and after the appearance of the skin eruption. 
Before the appearance of the eruption there is very little to guide 
us. Cough, coryza, and fever may accompany an influenza. In 
these cases the buccal eruption is of great diagnostic value. After 
the eruption appears, the question narrows itself to the differentia- 
tion of measles from rotheln or scarlet fever, and the recognition 
of the various forms of erythema, roseola, drug and antitoxin erup- 
tions. 

Treatment. — Prophylaxis. — As soon as the physician has made 
the diagnosis of measles or suspects its presence, the patient should 
be isolated from the other children of the family. Among the poor 
it is sometimes impossible to do this. The members of the family 
not directly concerned in the care of the patient should be denied 
admittance to the sick-room. It is not necessary to cover the door 
of the room with cloths or sheets moistened with disinfectants. The 
physician before entering the room should take off his coat and put 
on some convenient linen gown or bath-robe, so as to completely 
cover his person. This robe should hang outside the door of the 
room, so as to be easily accessible. When not in use, it should be 
hung in the open air. If the physician wears a beard, he should 
wash it after leaving the patient, for if the patient coughs in the 
physician's face, he is likely to carry the infection in his beard to 
the next child visited. Should the measles be complicated with 
diphtheria, extra precaution is necessary. 

General Treatment. — A typical case of measles needs little medici- 
nal treatment. We try to make the patient comfortable. The 
temperature of the room should be about 68°-70° F. (20°-21.1° 
C), if possible. The ventilation should be constant and attained 
by means of opening doors and windows of rooms communicating 
with the sick-room. It is not necessary to darken the room very 
much ; in fact, Bartels has shown that light and air are necessary to 
the comfort and well-being of the patient. The author has found 
that the ordinary yellow window-shade, if drawn over the windows, 
sufficiently excludes the actinic rays which are irritating to the eyes. 

In a typical case of measles a temperature of 104°-104.5° F. 
(40° C.) may be ignored. It should be remembered that the fever 
continues only during the period of the eruption. With the fading 
of the exanthema the temperature becomes normal. It is only in 



MEASLES. 157 

cases in which there is a high temperature with delirium that 
medication is called for. It is not uncommon to see children cov- 
ered with an eruption and with a temperature of 104° F. (40° C.) 
playing in bed with toys. 

The cough will sometimes need treatment. In such cases I 
am accustomed to prescribe Til iv (0.25) of paregoric combined with 
Vn ij (0.12) of syrup of ipecacuanha, every three hours. If the 
patient is kept awake by the cough, a small dose of Dover's powder 
(grains j or ij) (0.06 or 0.12) or codeine (grain ^ to ^) (0.006 to 
0.008) at night will be sufficient. If the patient is very restless at 
night and we do not wish to give opiates, grains v (0.3) of trional 
will quiet a child of five years. Some young children can be put to 
sleep by a small dose of phenacetin (grains ij) (0.1). In a mild case, 
especially if there is pruritus or irritation of the skin, there is no 
objection to sponging the patient once a day with water at 100° F. 
(37.7° C), containing some alcohol or a pinch of sodium bicarbonate. 

The food should be light. Milk, broths, and, when the fever has 
defervesced, chicken, soft-boiled eggs, jelly, toasted bread, crackers, 
rusk (Zwieback), and cereals in attractive form, with cocoa, comprise 
the diet list. Orange-juice or weak lemonade maybe given in mod- 
eration. AVater-ices may be given, if desired. 

As soon as desquamation has set in, I direct the body to be 
anointed every second day with an ointment of washed benzoinated 
lard combined with 5 per cent, of boric acid. The patient is 
allowed to get out of bed as soon as the temperature has fallen to 
normal, and is permitted to go out of doors three weeks after the 
outbreak of the eruption in the summer and four weeks in the winter 
months. Before mingling with other children, the patient should be 
thoroughly washed with soap. It is not necessary to put an anti- 
septic in the bath. 

The Treatment of Complications. — Bronchitis ; Bronchopneu- 
monia. — A severe inflammation of the finer bronchi is likely to 
cause as much fever, dyspnoea, cough, and restlessness as a primary 
bronchopneumonia. The temperature then rises and continues ele- 
vated— 104°, even 105° F. (40°-40.5° C.)— with morning remis- 
sions. In these cases the temperature must be reduced. I never 
hesitate to utilize hydriatic measures. The most convenient mode 
of applying water is by means of compresses moistened with water 
at 80° F. (26.5° C). if the patient reacts well, the compresses 
may be at 07° F. (19.4° C.) ; if he becomes cold and cyanosed, 
at 105° F. (40° C). These warm compresses are at times very 
soothing, causing the patient to drop into a quiet sleep. It should 
be remembered that the object of applying the compresses is not 
always to reduce temperature rapidly, but rather to stimulate the 
heart and support the patient. Douching the head with ice-cold 
water, as recommended by some, is a very questionable practice. 



158 THE SPECIFIC INFECTIOUS DISEASES. 

The use of the coal-tar antipyretics should be avoided. In lower- 
ing the temperature they act as depressants. In severe cases of 
bronchopneumonia aconite should not be used to lessen the rapidity 
of the pulse. Caffeine, camphor, strychnine, and digitalis in proper 
doses are more satisfactory. If a bronchopneumonia be prolonged 
into the convalescent stage, we should be on the alert for pleuritic 
effusion. This is especially likely to occur if the pneumonia lasts 
longer than two weeks. In these cases the symptoms present are 
similar to those described under Pleurisy, and the treatment is 
carried out on the same principles. 

The laryngeal symptoms become harassing when there is much 
swelling or slight erosions of the laryngeal mucous membrane. In 
such cases an improvised tent should be erected over the crib or bed 
and tilled with steam vapor saturated with thymol or turpentine. 
Older children can be persuaded to breathe the vapor generated in an 
open kettle. If symptoms of stenosis appear, it must at once be 
determined by culture whether a diphtheritic process, a streptococcic 
pseudomembranous formation, or a stenosis due to simple catarrhal 
oedema of the mucous membrane is present. 

Diphtheria. — Antitoxin is indicated in diphtheria either of 
the conjunctiva, pharynx, or larynx. A large dose should be 
given at the outset, on account of the virulent nature of this affec- 
tion as a complication of measles. We should not be too ready 
to intubate on the first appearance of stenotic symptoms. Many 
of these cases improve. The introduction of a tube into the 
inflamed larynx in measles is not without danger of causing ulcer- 
ations of a troublesome type after the measles has run its course. 
It is well to follow O'Dwyer's advice in such cases — withhold 
the tube as long as dangerous dyspnoea is absent. The use of 
apomorphine, tartar emetic, or turpeth mineral, so popular with 
continental physicians, to expel membrane or secretion, is of doubtful 
value. 

The Ear. — Otitis should be suspected if there is restlessness 
and an intermittent course of temperature without apparent cause. 
Older children may indicate the seat of pain. In some cases it may 
be necessary to incise the tympanic membrane. The procedure 
affords relief from pain, and is without ill effects. Pus or a few 
drops of serum only may be evacuated. 

Diarrhcea requires the same treatment as a primary enteric 
catarrh. 

The care of the eyes, nose, and mouth should be conducted 
on general lines. If the secretion is excessive, the eyes may be 
bathed once a day with a lukewarm weak saline solution. Unless 
the secretions are excessive, the nostrils should not be syringed or 
douched. If clots of mucus or pseudomembranous shreds form in 
plugs, they may be dislodged once a day by a nasal washing with a 



VARICELLA. 159 

suitable hand syringe. The mouth should not be washed more than 
once a day. This should be done both for infants who are fed 
artificially and for older children. On account of the great vulner- 
ability of the mucous membrane in this disease the utmost gentle- 
ness should be exercised lest aphthous ulceration be developed. 

VARICELLA. 

( Chickenpox ; ( Ger. ) U'indpocken. ) 

Varicella is an acute infectious disease with a characteristic exan- 
thematic eruption. It is distinct from vaccinia or variola, is an 
affection of childhood, occurring before the tenth year, rarely later, 
and is transmitted through the atmosphere. It cannot always be con- 
veyed by inoculation, as is the case with vaccinia or variola. It 
does not protect from vaccinia or variola. Varicella, vaccinia, and 
variola have been observed to attack the same patient successively 
at very short intervals. Few children escape after exposure, and one 
attack does not confer immunity. Varicella is an endemic disease, 
and does not occur epidemically. 

Incubation. — Varicella has a period of incubation during which 
competent observers have noted no disturbances (Henoch) ; others 
record malaise, corvza, and sore throat. The author is inclined to 
regard the prodromal period as free from symptoms. The period of 
incubation is usually fourteen days, but it may be protracted for 
nineteen days. 

The symptoms consist of an exanthema, an enanthema, fever, 
and slight malaise. There may be complications. Previous to the 
appearance of the exanthema there may be a slight febrile move- 
ment and malaise, which in children may pass unnoticed. In 
cases pursuing a normal course, a chill with a marked rise of tem- 
perature may precede the eruption by fully twelve hours. AVhen 
the eruption appears the temperature gradually falls, unless another 
crop of papules appears, when there is another sharp rise of tem- 
perature. Sore throat and slight malaise may herald the eruption. 
Previous to the appearance of the rash there may be, as in measles 
and in varioloid, an erythema of the surface prior to the appearance 
of the exanthema. 

The exanthema consists of an eruption of roseolar papules varying 
in size from that of a pin's head to that of a split pea. They first 
appear on the forehead and face, and spread to the trunk. In some 
- larger blotches appear, but these are of the nature of an 
erythema, which may precede the eruption of the roseola by a few 
hours. The roseolar papules have a characteristic violet-rose tint, 
are raise! above the surfaee, and are sometime- hard to the touch. 
In a few hours the papule develops on its summit a vesicle, which 
rapidly fills with lymph. These vesicles become tense, and if the 



160 



THE SPECIFIC INFECTIOUS DISEASES. 



papule is irregular in shape cover the whole upper surface of the 
papule. Iu many places the vesicle at the stage of its efflorescence 
presents an umbilication which strongly resembles that seen in the 
vaccinia pock. The contents of the vesicle become cloudy and then 
yellow ; the vesicle is surrounded by a dusky pink areola. In the 
course of a day or two the cycle is completed, and the vesicopustule 
begins to desiccate. A reddish-brown scab is developed. Many 
of the roseolar papules do not develop the vesicle and pustule. 
While one crop of papules is going through the cycle described 
above, others appear on various parts of the body. It is character- 
istic of varicella to have the surface covered with roseolar papules, 
papules with vesicles, and with pustules, in various stages of develop- 
ment. The papules vesicles, or pustules may be few or very abun- 



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Varicella temperature-curve showing successive rises 
vesicles. Boy aged six 



due to a new eruption of papules and 
years. 



dant. In some cases after the scab of the vesicle has fallen off a 
distinct scar is left, similar to that seen in vaccination, but much 
smaller ; it may persist for years. The skin between the papules 
and vesicopa pules is normal in color. 

The soft palate and sometimes the hard palate may show a few 
isolated papules, vesicles or vesicopustules similar to those seen on 
the cutaneous surface (enanthema). In most cases there is an 
angina, an injection of the conjunctivae or even an enanthema on 
the ocular conjunctiva (Henoch). Thomas records varicella papules 
and pustules on the nasal and vulvar mucous membrane (Fig. 36). 

The temperature is in many cases little raised above the normal. 
In others it reaches 103° F.*(39.4° C.) at the outset of the affec- 
tion. In rare cases 106.5° F. (41.3° C.) has been observed. As 



VARICELLA. 161 

soon as the eruption is fully developed the temperature rapidly 
becomes normal. The duration of the fever varies from one to 
three days. I have seen severe eases in which the high temperature 
persisted fully a week. The eruption was in these cases accom- 
panied by secondary pustulation. 

Other Symptoms. — Many infants and children show little consti- 
tutional disturbance. In other eases there is lack of appetite with 
excessive irritability. In others, on account of the profuse eruption 
in the vulva and around the nates, there is annoying vesical tenes- 
mus and even rectal tenesmus. The latter condition I have seen in 
a child two and a half years of age, in whom there was a profuse 
eruption of vesicles in and around the introitus vagina?, on the 
nympha?, and around the anus. There is in some cases a recru- 
descence of the exanthema in various parts of the body, with rises 
of temperature. 

Complications. — Gangrene of the skin with sloughing of large 
areas has been noted by some observers (varicella gaugrenosa). 
The conclusion is inevitable that iri many of these cases there must 
have been a mixed infection. 

Nephritis. — In many cases there is albumin in the urine to the 
extent of a trace. Henoch has described <i eases of varicella compli- 
cated with nephritis on the eighth to the fourteenth day after the 
appearance of the eruption. In these the eruption was profuse and 
accompanied by fever; there was oedema with albumin and casts in 
the urine. One case with fatty liver and moderate hypertrophy and 
dilatation of the left ventricle resulted fatally. Other authors 
have confirmed the observations of Henoch. I have seen slight 
albuminuria in some cases of varicella. 

Joint-affections. — I have observed two cases of varicella with 
swelling, pain, and effusion in one or both knee-joints. In 
neither was there suppuration. Both cases retrograded, and in a 
few days the joints became normal. The whole picture simulated 
what is seen in some cases of scarlet fever. There was no endo- 
carditis. 

Otitis may occur as a complication of severe cases. 

Pneumonia is an occasional complication (Fig. 37). 

The diagnosis of varicella should present few difficulties. I 
have seen a number of eases in which the eruption was not 
only very profuse, but the individual varicella vesicles or pus- 
tules were also very large. In these cases there may always arise 
the question of differentiation from the more serious affection, 
variola or varioloid, especially if an epidemic of smallpox is preva- 
lent. The diagnosis may even in some rare cases remain in doubt 
(Jurgensen). In varicella the temperature is lower and the rise 
shorter in duration than in even a mild ease of smallpox. In the 
absence of an epidemic, the mildness of constitutional symptoms, 
11 



162 



THE SPECIFIC INFECTIOUS DISEASES. 



discreteness of the varicella eruption, and the absence of any oedema 
of the skin between the vesicles will aid us. 

In some cases the eruption of roseola papules on the face and 
trunk has not the characteristic appearance of vesiculation or pustu- 
lation seen in varicella. It is difficult on account of the effects of 
the scratching of the patient to differentiate the eruption from pus- 
tules of a furuncular type. Under such conditions a close inspection 
of the back may result in the discovery of one or two typical 
varicella vesicles. 

The prognosis is very good in varicella, except in neglected 
cases, in which sepsis may complicate the disease. The very rare 

Fig. 37. 




Varicella bullosa, pneumonia, otitis media purulenta. Female child aged six years. 

cases of nephritis (Henoch) should be borne in mind. In private 
practice and in a large ambulatory clinic I have rarely seen the 
severer types of this disease. I agree with Furbringer in thinking 
that such cases raise the question of the possibility of an extraneous 
infection. 

Treatment. — Though the course of varicella is mild, the cases 
should be isolated like those of any other infectious contagious dis- 
ease. We can never predict the outcome of a number of cases 
occurring in epidemic form, although individual cases do well. If 
there are itching and tension, the eruption is covered with 5 per cent, 
boric acid ointment applied without lint. The children are allowed 
out of doors as soon as the temperature has become normal, the 
scabs of the varicella vesicles or pustules have fallen off, and the 
skin has become normal. 



VACCINATION. 



Vaccination is a prophylactic measure against variola practised 
on the human subject. It gives a certain, though not lasting, 
immunity against the disease. It is accomplished by inoculating 
the human subject with the contents of the cowpox vesicle. 

Cowpox or vaccinia (vacca, cow) is a specific exanthema which 









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VACCINATION. 163 

occurs on the udder of the milch cow, hence the name. Vaccinia 
is inoculable from animal to animal, and also on the human subject. 
It occurs only at the point of inoculation. 

Successful vaccination gives the human subject almost certain 
protection for a longtime against vaccinia or cowpox and variola or 
smallpox. 

The essential cause of vaccinia in animals and the human subject has been 
described by Guarnieri and Kurlow as vaccine corpuscles. These are found 
in the vaccine vesicle and pustule. They are peculiar, finely punctate, 
amoebic masses of protoplasm, showing vacuoles. Loudon and Salmon, on 
the other hand, deny any specific properties to these corpuscles. They think 
they are simply degenerated leucocytes, and are seen in other simple forms 
of inflammation. 

Edward Jenner (1 749-1823) was the first to establish the doc- 
trine of vaccination on scientific experimental data. He Avas the 
first to use humanized vaccine— that is to say, to inoculate the human 
subject with lymph from a cowpox vesicle, and then to utilize the 
lymph of the vesicle in the human subject to inoculate others. This 
method has been abandoned. To-day the lymph used is obtained 
directly from the animal. The lymph is, as a rule, inoculated from 
animal to animal for several generations. It is just as effective as 
the lymph of the first animal of the series inoculated. It is called 
animal lymph or vaccine. The disadvantages of using humanized 
vaccine are many. First, there is a natural reluctance among some 
people to vaccinate their children with lymph obtained from the 
human subject. Apart from the popular belief in the transmission 
of tuberculosis, scrofula, and other forms of blood disease in this 
way. it is not always possible to exclude an infection, such as syphilis. 
The animal lymph can be controlled in its manufacture and produced 
with all scientific precautions. Animal lymph and human lymph do 
not differ in the power to confer immunity against variola. The 
animal lymph should be obtained from the healthy animal in the 
vesicular stage of the eruption ; this is the fourth or fifth day of 
cowpox. It is preserved by mixing it with three or four times its 
bulk of glycerin. It may be put up for use on quills or ivory slips 
in a dry state or in small capillary tubes in the liquid condition. 
The so-called vaccine pulp, made up of the contents of the vesicle 
and it- epidermal covering, and preserved in glycerin, is not used in 
this country. 

Age at which to Vaccinate. — Every infant and child should bz 
vaccinated. There is no contraindication except some acute or 
chronic illness. Even the hemorrhagic diathesis is no contraindica- 
tion. Vaccination is best done between the fourth and the sixth 
month, before teething lias begun (Zimmerman). In an emergency, 
such as the presence of an epidemic of smallpox, the newly born 
infant may be vaccinated. 

Mode of Vaccination. — Boys are vaccinated on the left arm ; girls, 



164 THE SPECIFIC INFECTIOUS DISEASES. 

for esthetic reasons, may be vaccinated on the thigh or calf of the 
leg instead. The outer surface of the arm, at about the insertion of 
the deltoid in the humerus, is usually selected. The skin is carefully 
cleansed with soap and water, washed with alcohol, and dried. 
A\ ith a clean sewing-needle the skin is scarified three or four times 
in one direction, and at right angles to the first scarifications. We 
should not cause bleeding, but only expose a raw surface. The 
scarified area should be about one-eighth of an inch square. The 
lymph is now rubbed on the scarified area. If quills are used, the 
vaccine on the quill is moistened with a drop of distilled water 
before inoculation. Scarifying large areas is likely to cause exces- 
sively large pustules, with subsequent severe inflammatory reaction. 
On the other hand, a small area of scarification may give a very large 
pustule. In other words, the size of the vaccine pustule does not 
always depend upon the size of the area of scarification. A mixed 
infection will give a severe reaction with a very small area of scari- 
fication. 

Lymph to Use. — Either the liquid or the dry lymph may be used. 
Both are reliable if recently prepared. If the lymph is not fresh, or 
there is carelessness in its use, the vaccination will be a failure. 

Course of the Vaccination. — The great majority of vaccinations 
are very uniform in history. There is an incubation period, during 
which the wound heals. There are absolutely no symptoms. This 
period usually lasts three days, sometimes only two, and may be 
prolonged to four or six days. After this period there is the erup- 
tive stage, ushered in by the formation of flat rose-red papules 
at the points of scarification. The papules are either oval or 
irregularly long. On the fifth day a vesicle appears in the centre 
of the papule and spreads to the periphery. On the sixth day 
the vesicle takes up the whole papule, has a pearly lustre at the 
surface, and presents a central umbilication (Jenner's vesicles). 
The seventh day is the day of efflorescence ; the vesicle is filled and 
tense with lymph, has a rose-red areola and a hypersemic zone out- 
side this areola ; there are itching and tension. On the eighth day 
the contents of the vesicle become slightly cloudy. On the ninth 
day the suppuration is pronounced, and on the tenth day the sup- 
puration, swelling, and inflammatory reaction are at their height. At 
the end of the tenth day there is a retrogression of all the symptoms. 
The vaccine pustule becomes less angry looking and the inflamma- 
tory reaction subsides. A crust forms which may become dry, 
hard, and fall off, leaving a scar beneath. This takes, as a rule, from 
ten to fourteen days. 

Fever in some cases begins on the fifth day after vaccination. 
It may be slight and reach its height between the eighth and the 
tenth day. There may at this time be slight digestive disturbances, 
such as vomiting or greenish movements. 



VACCINATION. 165 

The areola around the vaccine pustule may spread so as to 
involve most of the upper part of the arm, or the inflammatory 

reaction may spread over the entire arm, and sometimes over the 
back. There may be enlargement of the lymph-nodes in the axillae. 
These lymph-nodes may suppurate. If there has been no mixed 
infection, they retrograde with the pustule. 

Complications. — Complications may result from traumatism of 
the pustule, mixed infection (that is, the presence of impurities, such 
as streptococci or staphylococci in the lymph), lack of cleanliness at 
the time of maturation of the pustule, and retention of pus in a dress- 
ing. The most common complication is an exceedingly severe reaction, 
with an extensive necrosis of tissue. This may affect the fasciae or 
muscular layers, causing large loss of tissue. Among the rarer com- 
plications of vaccination is a true septic infection. In these cases 
there is a history of mismanagement of the pustule, such as trauma- 
tism or the compression of the arm by a bandage. Infection which 
manifests itself in a remittent febrile curve occurs. In one case 
which came under my notice a few pus-corpuscles appeared in the 
urine, the elbow-joint and other joints became painful and swollen, 
and suppuration in the joints resulted. These cases are fatal. 
There is a true osteomyelitis of the heads of the bones, with forma- 
tion of pus in the joints. In other cases the child may by scratch- 
ing inoculate itself elsewhere, either on the arms or even lips and 
eyelids ; the latter condition has come to my notice. It forms a 
very painful and severe complication. Erysipelas may set in early 
or late in the history of the vaccination. It may spread down the 
arm and forearm on the trunk and may endanger the life of the 
patient. In other cases there may be suppuration of lymph-nodes. 
In susceptible subjects a rebellious eczema may appear as a direct 
sequence of the vaccination. Among the complications may be 
mentioned axillary adenitis, hemorrhage into the pock (trauma), 
exuberant granulations, and keloid of the scar. Tetanus may 
result from infection of the wound with the bacilli of tetanus which 
may be present in uncleanly dressings. 

Generalized Vaccinia. — This is a general eruption of vaccine pus- 
tules, which in rare eases appears from the third to the seventh day 
over the whole trunk and extremities. It is really a generalized 
cowpox, similar to the generalized eruption in the exanthemata. 
D'Espinc and Jeandin describe cases in which there can be no doubt 
of the absence of infection of the surface by the nails or otherwise. 
The prognosis in these eases is good ; there are no severe symp- 
toms, and the fever is slight. 

The management of a normal case of vaccination is important. 
We should protect the vesicle from traumatism by means of some 
simple contrivance, such ;i- a shield. If the areola is angry looking 
and the redness and swelling severe, we may paint it once a day with 



166 THE SPECIFIC INFECTIOUS DISEASES. 

compound tincture of benzoin. This is very soothing and protects 
the surface from friction. If complications occur, they should be 
treated on surgical principles. Above all, there should be no reten- 
tion of pus by any form of dressing. Dressings which seal the 
vaccine pustule hermetically from the air cause retention, and are 
therefore dangerous. Sepsis as described above is not the result of 
vaccination, but of subsequent mismanagement. 

Vaccination Eruptions. — The eruptions which follow vaccination 
or occur while the pustule is still in course of development are of 
interest. Sobel has made an exhaustive study of these eruptions. 
Fully 14 per cent, of the vaccinations are followed by more or less 
generalized eruptions. They appear while the local site of the vacci- 
nation is open or as late as eight weeks after the primary inoculation, 
but most often between the ninth and the fourteenth day after 
inoculation. They have no relation to the size or severity of the 
local pustule, which may be normal. Among the types of eruptions 
are the erythematous, urticarial, papular, vesicular, pustular, mor- 
billiform, bullous, pemphigoid, and scarlatiniform. Auto-inoculation 
by scratching generally occurs an inch or two from the original site, 
but it may occur elsewhere, as on the eyelid or conjunctiva. The 
most common type of generalized eruption is undoubtedly the 
urticarial in its various forms. These include wheals, papules, 
bullae, and vesicopapules. The morbilliform are easily differentiated 
by the absence of fever and coryza and other signs of measles. The 
scarlatinal forms cause great uneasiness and elevation of temperature. 
These cases should be observed for urinary complications and subse- 
quent desquamation, in order to exclude scarlet fever. Among the 
rarer types are the ecthymatous eruptions. 

Revaccination. — Vaccination should be repeated after the lapse 
of ten years, and every five years thereafter. During an epidemic, 
every one who has not been re vaccinated should be vaccinated. 
Immunity to variola diminishes as we reach the termination of the 
first decade after the first vaccination. If the revaccination runs a 
typical course identical with that of the original vaccination, immu- 
nity is generally lasting. 



OTHER SPECIFIC INFECTIOUS DISEASES, 
TYPHOID FEVER. 

(Abdominal Typhus ; Ileotyphus.) 

Occurrence. — Of 84 cases of typhoid fever treated by the 
author, 38 were of the male and 46 of the female sex. The ages 
were as follows : 1 was of eighteen months, 4 were three years, 9 
were four years, 41 were between the fifth and the tenth year, and 



TYPHOID FEVER. 167 

the remaining cases ranged up to the fourteenth year. Thus 16 
per cent, occurred before the fifth year, and fully 50 per cent, from 
the tilth to the tenth year. 

Typhoid Fever and Pregnancy. — According to Etienne, quoted by 
Morse, the foetus in utero is born prematurely in 70 per cent, of the 
cases of typhoid fever in the mother. The causes of the abortion 
are much the same as those which obtain in pregnant women suffer- 
ing from any infectious disease. The high temperature, the toxins 
in the circulation of the mother, and the death of the foetus, all con- 
tribute to cause miscarriage. Morse believes that the death of the 
foetus is chiefly instrumental in causing its expulsion. Of 12 abor- 
tions, 9 were stillbirths, 2 lived four and 1 Ave days. 

Foetal Typhoid. — Though doubt has recently been cast upon the 
results of Chantemesse and Widal, there is good reason for believing 
that the Bacillus typhosus (Eberth) can pass through the healthy or 
diseased placenta from mother to foetus (Morse). This has been 
proved by experiments in animals (Widal,,. Chantemesse). The 
typhoid bacillus has been found in the organs of the foetus and in 
the amniotic fluid. 

The anatomical changes found in the foetus affected by typhoid 
fever are not identical with those seen in the adult. This is due to 
the fact that the infection of the foetus is hematogenous, which 
explains the high fetal mortality. The spleen is sometimes though 
not always enlarged. The changes in the gut are not characteristic, 
being confined to a few enlarged follicles. The liver may be 
enlarged, and the kidney may show hemorrhages. 

Infantile Typhoid. — It has recently been contended that typhoid 
fever is rare in the infant or the child under two years of age. 
AVith the improved methods of laboratory diagnosis of typhoid fever 
we may shortly be in a position to determine the relative frequency 
of the disease in the newly born and the young infant. Typhoid 
fever certainly occurs under the age of two years. As Crozer 
Griffith has pointed out, we should think of the possibility of its 
presence in every case of continued remittent fever of the nursling 
not to be explained on other grounds. Of 331 cases, 9 under two 
years of age were diagnosed by Henoch as typhoid fever. Among 
others who report cases are Ollivier, Noyes, Northrup, and Bell. I 
have seen only 2 cases under two years. Blackader, in a recent 
scries of 100 cases, met 4 under two years of age. Gerhardt reports 
a ease in an infant twenty-five days old, and Blumer 1 in an infant 
five days old. These cases may be regarded as either congenital or 
post-natal typhoid. 

Morbid Anatomy. — It lias been stated that when the foetus 
in utero is affected with typhoid fever the process is in the 
nature of a hematogenous infection, and that there are few if any 
characteristic anatomical changes. In young infants and children 



168 THE SPECIFIC INFECTIOUS DISEASES. 

the changes in the gut so characteristic of adult cases are not always 
seen in their full development. The solitary follicles and Peyer's 
patches are enlarged, but ulcerations are seen only here and there, 
and seldom lead to perforation (Monti). On the other hand, in 
older children the changes in the gut closely resemble those of the 
adult, as has been shown by Henoch. The mesenteric lymph-nodes, 
especially those in the vicinity of the ileocecal valve, are enlarged. 
The remaining changes resemble those seen in the adult subject. 

Symptoms. — The invasion of the disease in young children is 
rarely with a chill. More frequently there are indefinite chilly sen- 
sations and mild general malaise. There are headache, pains in the 
limbs, vertigo, and in many cases vomiting. The symptoms of the 
period of invasion are so very indefinite in infants and very young 
children that cases sometimes escape diagnosis. 

In other cases, after a few days of malaise the cerebral symptoms 
become marked. The headache is augmented by delirium at night, 
especially in older children, and stupor is present. In younger chil- 
dren the period of invasion may simulate a pneumonia. In fact, 
these cases begin as pneumonia, and it is only on careful considera- 
tion of the clinical symptoms — the predominance in a few cases 
of cerebral symptoms or the enlarged spleen, and the presence of 
roseola later on, with the elevation of temperature — that we are led to 
think of typhoid fever. In some of these pneumonic cases there are 
none of the characteristic features of typhoid. There is no roseola, 
no splenic enlargement, no epistaxis, but there may be diarrhoea. 
During an epidemic only the systematic examination of the blood 
(Widal) will reveal these cases. Such a case is the following : A 
child, five years of age, was admitted to my hospital service with an 
indefinite previous history. Temperature 104.6° F. (40.3° C), 
pulse 140, and respirations 30. There was apathy, also a broncho- 
pneumonia in the upper lobe of the left lung. This case gave a 
very positive Widal reaction early in the disease. The spleen 
became palpable four days after admission. In another case, of a 
child four years of age, signs of a lobar pneumonia of the upper 
lobe of the left lung were present without any roseola, enlarged 
spleen, diarrhoea, or abdominal symptoms. On the fifth day of the 
disease the Widal reaction became positive in a dilution of 1 : 50. 
This child died on the sixth day of the disease, with increasing signs 
of pneumonia and a positive Widal reaction of 1 : 350. Many of 
these cases of typhoid fever in older children become comatose after 
the first week. Such a case was recently admitted to my wards. 
The onset was with headache and fever. There Avas no vomiting, 
epistaxis, or chill. The child became unconscious, with a tempera- 
ture of 106° F. (41.1° C), rigidity of the muscles of the neck, 
increased reflexes, ankle-clonus, Kernig's symptom, and enlarged 
spleen. This case gave a positive reaction to the Widal test, and 



TYPHOID FEVER. 



169 



lumbar puncture failed to reveal anything characteristic in the fluid 
withdrawn. 

The invasion is not characteristic in infants. In exceptional 
eases (Blackader) a convulsion is the first symptom noted. In some 
cases there may be a simple continued fever with diarrhoea, without 
other symptoms. In a case reported by Crozer Griffith the roseola 
and the enlarged spleen were present. 

The subsequent history of a case varies with the character of the 
infection. In the forms which have a slow, gradual onset the chil- 
dren remain for a time in good physical condition. During the first 
w r eek the sensorium is clear, the tongue coated, and the face of 
good color ; the spleen may be readily palpable, the roseola appears, 
and there may be diarrhoea or constipation. In some cases the iliac 



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Typhoid fever which began as a lobar pneumonia in a girl four years of age. Consolidation 
of the lower lobe of the left lung; death on the tenth day of the disease. 

tenderness is marked ; in others absent. It may not be possible to 
determine the presence of ileocecal tenderness in young children. 
The symptoms after the first week may be augmented by delirium at 
night ; in older children this delirium, which has much the same 
character as in the adult, is also present during the day. Children 
from five to seven years of age are more likely to have the quiet 
form of delirium, while older children are noisy and try to get out 
of bed. 

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tardy in those cases which recover. To the symptoms of pneu- 
monia are added after a time those of typhoid fever — roseola and 
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resembles that of the sustained remittent type (Fig. 38). In some 
cases pleurisy may be present. 



170 THE SPECIFIC INFECTIOUS DISEASES. 

In the newly born infant to whom the fever has been conveyed in 
utero the picture of the disease is unlike that seen in older infants 
and children. The symptoms resemble those of sepsis of the new- 
born. Thus in the case published by Blumer the first symptom of 
the disease was an uncontrollable hemorrhage from the vagina. 
Before death this was supplemented by hemorrhages into the skin 
and from the gums. 

The cases of typhoid fever in infancy thus far recorded by 
Morse, Crozer Griffith, Blackader, and the author, may be divided 
into two classes : those in which there is a mild diarrhoea with dis- 
tention of the abdomen, roseola, and enlarged spleen ; and those 
which present cerebral symptoms. The latter develop coma, have 
a distended abdomen, rose spots, and enlarged spleen. In both 
forms there are severe and mild types. Cases in which the tempera- 
ture rarely rises above 104° F. (40° C.) recover, while those with a 
higher temperature may be fatal. 

Individual Symptoms. — Boseola. — In children, as in the adult, 
the roseolar papules are seldom absent. In some cases their number 
is large, while in others they are few and widely scattered over the 
surface. They may appear in successive croj3S, and reappear in a 
relapse. Occasionally the roseola is preceded by a diffuse erythema 
closely resembling the scarlet fever eruption. The roseola may, as 
in the adult, appear on the third, fifth, or tenth day, and may even 
be delayed until the end of the second week, after which it gradually 
fades, leaving a pigmented area. The eruption is sometimes so pro- 
fuse as to resemble the eruption of typhus. It may be profuse in 
cases in which the cerebral symptoms are very marked. I have 
seen typhoid fever with severe cerebral symptoms, but with an 
eruption very sparse or entirely absent at the height of the disease. 
In severe delirious cases, hemorrhagic areas appear on the bony 
prominences of the shoulders and extremities. Petechia? are common. 
In protracted cases extensive purpuric areas appear on the abdomen. 
These hemorrhagic cases are not necessarily fatal. 

The enlarged spleen is one of the most common physical 
signs. At the outset of the disease it is not always easy to pal- 
pate the spleen. This is especially true of younger children. The 
enlarged spleen is present not only in older children, but also in 
cases of foetal typhoid fever. I have seen the enlargement persist 
for weeks after convalescence. In one case the spleen could be 
distinctly felt below the border of the ribs for a long time after 
recovery. 

In some forms of relapse the spleen enlarges after having dimin- 
ished to the normal size. Cases in which the spleen remains 
enlarged a long time are likely to have slight rises of temperature 
of short duration. Typical relapses without enlargement of the 
spleen may occur. The fact that the spleen continues enlarged after 



TYPHOID FEVER. 



171 



the temperature has become normal 
does not always indicate the ap- 
proach of a relapse. 

Temperature. — An elevation of 
temperature in young children is 
usually not observed during the first 
eight days. Children rarely complain 
of slight malaise, and a rise of a de- 
gree or even more above the normal 
may escape notice ; as a result, the 
impression is prevalent that the tem- 
perature during the first week does not 
follow the typical curve. The cases 
which 1 have observed sufficiently 
early, and which were not complicated 
with pneumonia, showed during the first 
week the gradual rise seen in the adult 
(Fig. 39). This gradual daily rise of 
temperature is also seen in relapses. On 
each day the temperature at its highest 
point is higher than on the previous 
day. After the first week the tem- 
perature is likely to show a remittent 
curve with a sustained maximum 
point. After the second week the 
temperature may remit, gradually fall- 
ing, or intermit ; frequently it re- 
mains high for weeks, with daily re- 
missions. Bv the end of the second 
week it reaches 104° to 105° F. (40° 
to 40.5° C.) at its highest. In the 
course of the third, fourth, and fifth 
weeks it may range a decree lower, 
with remissions to 101° F. (38.3° C), 
not reaching the normal. If the case 
is protracted, the temperature may per- 
sist into the sixth week, running up as 
highas 106° F. (41.1° C), falling fully 
five decrees twice daily. In one case 
the temperature did not become normal 
until the eighth week. Even at this 
late period there may be relapse-. In 
many cases the temperature falls to the 
normal after six or seven weeks, or 
becomes subnormal, and then after an 
interval of a few days or a week rises 





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THE SPECIFIC INFECTIOUS DISEASES. 



and fluctuates a degree or more above the normal. This continues 
for a few days, the temperature remitting to the normal or near the 
normal. These post-typhoidal fluctuations are sometimes mistaken 
for relapses. They are rather to be attributed to inanition, or are 
the result of slight absorption from the gut. In a large number of 
cases the first sign of convalescence is a subnormal temperature. 
On the other hand, the temperature may be subnormal for a week 
or more and relapse follow (Fig. 40). 

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children show r s a gradual rise of temperature. The subsequent tem- 
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Typhoid fever of short duration in a boy six years of age. 

lobar pneumonia or a bronchopneumonia will cause a persistence 
of the high temperature, as will also other conditions, such as otitis. 

The inverted type of temperature-curve is described by Henoch. 
The morning temperature is higher than the evening, or there may 
be a rise at 3 A. M. or 6 A. m., a fall in the forenoon, with a rise 
again at noon, and a fall toward evening. Such a curve may be fol- 
lowed within a day or two by the usual fall in the morning and rise 
toward evening. These fluctuations occur at the height and at the 
decline of the disease. 

Hemorrhages from the bowel are not so common in children as 
in the adult. I have seen persistent hemorrhages in only 4 out of 
84 cases. In one case I have met post-typhoidal ulcerative colitis. 
The bowels may be constipated, normal, or diarrhoeal. The number 
of stools varies. In the majority of cases diarrhoea is absent. In 
some the temperature in convalescence may rise a degree or more for 
a day or two. In these cases there may be fecal accumulation due 
to incomplete evacuation of the gut. 



TYPHOID FEVER. 173 

SensitiveDess in the ileocecal region is very difficult to determine 
in young children. In older children it is sometimes marked, and 
indicates ulcerative processes in that region or in the neighborhood 
of the appendix. Perforation is rare in children. In the case of a 
boy of nine years the pain, collapse, elevation of temperature, and 
rise of the pulse above 120 indicated perforation, but operation 
revealed no perforation. Recovery resulted. In another case, also 
a boy of nine years, there was great ileocecal tenderness, with a sud- 
den rise of temperature and local rigidity, but the pulse remained 
below 120. There was an increase in the number of leucocytes to 
10,000. There may have been ulceration and localized peritoneal 
reaction in this case, but no perforation. 

Otitis is not uncommon. I have seen several cases. 

I observed parotitis in only one case. 

The tongue of children with typhoid fever resembles that of the 
adult. It is at first coated, and is protruded in a tremulous man- 
ner ; subsequently the epithelium is thrown off and the papilla? 
become prominent. In some cases the tongue resembles the so-called 
strawberry tongue seen in scarlet fever. At the height of the dis- 
ease it may become dry and fissured, and sordes may collect on the 
teeth. The lips become fissured and bleed easily. 

The nervous symptoms of older children resemble those of the 
adult. With younger children sopor is the rule and delirium is 
infrequent. Melancholia or depression occasionally is met with in 
convalescence, usually in girls of hysterical temperament. 

The Heart. — In a recent epidemic of typhoid many cases showed 
systolic apex-murmurs. These murmurs were loudest over the base, 
close to the sternum, or over the pulmonary orifice. Such murmurs 
are myocarditic. In one case there was a loud musical systolic 
murmur heard over the apex of the heart. It was also heard at the 
base of the heart. The murmur appeared early iu the third week. 
There was also a pleuropericardial friction-sound. Post-mortem 
examination revealed myocarditis and pleuropericardial adhesion. 

The Lungs. — The occurrence of lobar or lobular pneumonia late 
in the course of typhoid is serious. At this time the patient's pow- 
ers of resistance are greatly diminished. Especially grave are the 
cases which show a sustained high temperature for two or three 
weeks, and then develop pneumonia. If with the pneumonia there 
are extensive hemorrhages under the skin at the situation of the 
bony prominences, the outlook is grave. In such a case I have seen 
a pneumonia involve the whole lobe of the lung in consolidation 
within a few hours. 

The Blood. — In children, as in the adult, the number of red blood- 
cells diminishes, and reaches the lowest point at the end of the febrile 
period. The haemoglobin also is diminished. The leucocytes are 
diminished from the outset until convalescence, but increase after 



174 



THE SPECIFIC INFECTIOUS DISEASES. 





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it is established. In one of my 
cases their number fell to 3500, 
and then rose to 12,400. In a 
case complicated with extensive 
ulceration in the gut and bron- 
chopneumonia they numbered 
30,000. In fatal cases compli- 
cated with lobar pneumonia I 
have found them as low as 4500. 
According to Thayer, the poly- 
nuclear neutrophiles steadily di- 
minish as convalescence ap- 
proaches, while the mononuclear 
leucocytes and eosinophiles in- 
crease. With the establishment 
of convalescence blood conditions 
return to the normal. 

Relapses. — A relapse is a 
gradually ascending temperature- 
curve extending over a week or 
longer after the temperature has 
been normal for a time (Fig. 41). 
A relapse Avas noted in 7 of 46 
cases of my last series. In all, 
it was mild and no serious results 
followed. On the other hand, a 
prolonged low febrile curve causes 
great emaciation in children. Im- 
portance has been attached to the 
condition of the spleen in these 
cases. The percentage of relapses 
varies with the nature of the pre- 
vailing epidemic. Blackader re- 
cords 15 relapses in 100 cases, 
and Henoch 44 in 375 cases. Ap- 
parently relapses occur indepen- 
dently of the mode of treatment 
and diet. 

Complications and Sequelae. 
— Skin. — Subcutaneous abscesses 
may occur, and onychia is com- 
mon. Erysipelas and parotitis 
are rare. CEdema may be con- 
fined to the scrotum, or during 
defervescence the whole surface 
of the body may be cedematous, 



TYPHOID FEVER. 175 

In a case of scrotal oedema coming under my observation there were 
no easts or albumin in the urine ; the leucocytes were diminished. 
Henoch attributes oedema to cardiac weakness rather than to ne- 
phritis. 

Diphtheria is a very serious complication. I have observed it in 
2 out of 84 cases. 

Lungs. — Bronchitis is a frequent complication. In the later 
stage- of the disease in younger children it is likely to develop into 
bronchopneumonia, especially in eases in which the course of the 
disease is protracted. Pneumonia may occur. Gangrene of the lung 
is mentioned by Henoch as a rare complication. 

Arthritis is uncommon. Usually only one joint is affected. It 
occurs in the post-typhoidal period and runs a favorable course. 

Among the nervous symptoms which complicate or follow typhoid 
fever are aphasia, amblyopia, ataxia of the lower extremities, par- 
alyses of various sets of muscles, double ptosis, and hemiplegia. In 
hysterical children there may be a post-typhoidal melancholia. In 
others stupidity may persist for a time. Recovery usually takes 
place in all forms of paralysis, aphasia, or melancholia. The 
paralyses are possibly due to a neuritis of toxic origin, as is the 
case with the other infectious diseases. Hemiplegia occurs only as 
a result of embolism (Henoch). I have met cases of ataxia and 
marked melancholia. The children made an excellent recovery. In 
one case, a boy of four years, catalepsy was present for a period of 
five weeks after the temperature had become normal. 

The duration of typhoid fever varies within wide limits. 
Henoch in his tabulation of more than two hundred cases shows 
that the shortest duration was seven to nine days ; the longest, 
seventy days. Relapses and conditions of inanition are not in- 
cluded. In my cases the duration varied widely if the recurrent 
rises of temperature were taken into account. In 30 cases the 
shortest duration of the fever, exclusive of relapses, was ten days ; 
the longest, forty-six day- ; the average duration, twenty-one and 
one-third days. Including the relapse, which continued forty-eight 
days, one case lasted seventy-five days, the original fever having 
lasted twenty-six days. 

Diagnosis. — Enough has been said to show that the diagnosis 
of typhoid fever in infancy and childhood is at times very difficult. 
With young children enteritis, pneumonia, meningitis, and even 
appendicitis may simulate typhoid fever in their onset. Cases 
which begin as a pneumonia are especially difficult of diagnosis. 
The cerebral forms of typhoid fever may closely resemble meningi- 
tis. The history is very important. The onset of typhoid fever is 
gradual, the cerebral symptoms increasing in intensity as the disease 
progresses. An enlarged spleen and a few roseolar papules will 
be of service in making a diagnosis, but, on the other hand, an enlarged 



176 THE SPECIFIC INFECTIOUS DISEASES. 

spleen is common to many conditions of infancy and childhood. In 
the most puzzling cases, such as those simulating enteritis of non- 
tvphoidal nature, the roseola may at the outset be absent. 

In a doubtful case the Widal blood-test should be made daily to 
clear up the diagnosis. In many cases this reaction is the only clue 
to the condition. During the prevalence of an epidemic every case 
of pneumonia or doubtful meningitis or enteritis should be subjected 
to this test. 

The Widal agglutination reaction is of greater utility in making a 
positive diagnosis of typhoid fever in children than in adults. The 
fact that an enlarged spleen may be due to various causes, such as 
rickets, the occurrence of fevers of a remittent or continued type, 
possibly due to otitis, enteritis, pneumonia, and the prevalence of 
diarrhoea of all kinds in infants and children, tend to make the 
Widal test of inestimable value. 

In a paper based on 84 of my cases of typhoid fever in infants 
and children, Gershel found the reaction positive in 81. Three 
hundred and twenty-nine examinations in all were made. Thirty- 
six were positive on the first test, and forty-five on repeated tests. 
The reaction appeared in 5 cases on the fifth day, in 3 cases on the 
sixth day, and in 3 on the seventh day. In other words, 13 per 
cent, of the tests were positive at the end of the seventh day, 63 per 
cent, on the fifteenth day, and 89 per cent, on the twenty-fifth day 
of the disease. The reaction was negative in only 3 cases which 
gave the clinical symptoms of typhoid fever. These figures corre- 
spond to those obtained by Blackader in a smaller number of cases. 
A negative reaction is of no significance as excluding typhoid fever, 
whereas a positive reaction is absolutely pathognomonic of the disease. 
Though 115 of my fever cases were examined by this test for the 
presence of typhoid fever, exclusive of the above 84 cases, the reaction 
was obtained in no case in which typhoid was not present. In a few 
cases the reaction was not obtained until the close of the disease, 
when the temperature had been normal for some days. In another 
case of a child of three years, the reaction was not obtained until a 
relapse had occurred. In the case of a boy of seven years the 
reaction was not obtained until the third week. It was not taken 
again until the onset of a relapse in the fifth week, and was negative. 
It subsequently became positive at the termination of the relapse. 
This proves that a negative test is of little significance in excluding 
the possibility of typhoid fever unless the examinations extend over 
a long period. The presence of the reaction in typhoid fevers 
which begin with a pneumonia is of interest. In one of these cases, 
fatal on the eighth day, in a child four years of age, the reaction was 
negative until the fourth day of the pneumonia. It became positive 
in an attenuation of 1 : 350 just before the exitus lethalis. 

The Ehrlich Diazo Reaction in the Urine. — Thirty-three cases were 



TYPHOID FEVER. 177 

examined with reference to this reaction. The fifth day was the 
earliest day on which it was obtained. In the majority of cases the 
reaction was present from the seventh to the tenth day of the disease. 
The latest appearance was on the forty-seventh day from the outset 
of the disease. The reaction was absent in 15 per cent, of the cases. 
In all of the cases in which the Ehrlich reaction was obtained the 
Widal test was positive, and appeared in the first two weeks of the 
disease. The reaction may be present, as it was in one case, on the 
fifteenth day, and be absent on the next. The diazo reaction may 
appear before the Widal reaction, but in some cases the contrary is 
true. In conclusion, it may be said that in the presence of symp- 
toms and signs of typhoid fever the diazo reaction is an aid to diag- 
nosis, although not pathognomonic of the disease. 

Of the clinical signs pointing to typhoid fever, the character 
of fever aids us but little. In the third week it may become 
intermittent, thus simulating malarial fever. In other cases the 
fever may be sustained with daily remissions until the fifth week. 
Typhoid fever with great ileocecal tenderness and pain may closely 
simulate appeudicitis. In a recent case published by Berg, ope- 
rated upon for appendicitis, the operation revealed that the patient 
w as suffering from a perforation of the appendix due to an ulcer 
of typhoidal origin. A continued fever of longer duration than a 
week, a tremulous tongue, facies, a pulse below 120, an enlarged 
spleen, and a few roseolar spots, will aid in the diagnosis. The 
diagnosis of perforation of the gut is. not always simple in chil- 
dren. In these subjects tympanites is not uncommon, aside from the 
presence of peritonitis. I have cited a case in which all signs 
pointed to perforation, and yet operation revealed nothing. The 
classical signs of perforation are those of collapse, a sudden fall of 
the temperature, and a rise of the pulse above its normal frequency, 
an increase of the leucocytes, and the presence of tympanites increas- 
ing until it causes a disappearance of the liver dulness. No one of 
these symptoms is absolutely pathognomonic. In many cases we shall 
be compelled to draw conclusions from the general history of the case. 

The diagnosis of typhoid fever must, therefore, be confirmed by 
the Widal reaction, except in a small percentage of cases. The 
presence of roseola, enlarged spleen, facies, trumulous tongue, diar- 
rhoea, and continued remittent fever are the clinical symptoms which 
should lead the physician to apply the test. 

The prognosis of typhoid fever in infancy and childhood is, as 
a rule, good. The mortality varies with the severity of the infection 
and the character of the epidemic. If the infection is severe, the 
complications will militate against recovery. Henoch, in 375 eases 
had a mortality of 14 per cent.; Blackader, in 100 eases lost only 
1 : Crozer Griffith had a mortality of 3 per cent., and in my last 
series of 4<; cases the mortality was 8.7 per cent. 

12 



178 THE SPECIFIC INFECTIOUS DISEASES. 

The treatment of mild cases of typhoid fever is purely symp- 
tomatic. There is little need for the administration of medicines. 
On the other hand, the severer cases are difficult, to manage. This 
is especially true in the treatment of children, to whom it is not 
always possible to apply methods adopted with the adult. In cases 
in which delirium is present night and day bromides in large doses 
are efficacious. With older children they may prove useless, and 
morphine may then be necessary to meet the exigencies of the case. 

In the vast majority of cases milk forms the basis of the 
diet. If there is progressive emaciation, one, two, or three raw eggs 
should be added to the milk daily. It is well in protracted cases not 
to wait too long for a complete drop of temperature before resorting 
to other foods than milk. This is especially true of cases extending 
over a period of seven or eight weeks, in which there is always a rise 
of temperature of half a degree or a degree above the normal for a 
few days, with a drop again to the normal or subnormal. In these 
cases there is a form of inanition fever, post-typhoidal in nature. 
Solid food should not be withheld too long lest the emaciation become 
extreme. After the fifth week we may in most cases allow the patient 
gruels containing cereals. After the temperature has fallen to the 
normal and remained there for four or five days, it is safe to return 
gradually to a full diet. It is doubtful if relapses occur as a result 
of too early feeding if this method is followed. In comatose states 
resort may be had to forced feeding. 

Alcohol is not needed in mild cases. It is given in cases in which 
the pulse is weak and the temperature high. Delirium is no contra- 
indication to its use, as it is in other affections. 

The heart is stimulated by digitalis, strychnine, or camphor. If 
the heart has shown slight dilatation with a murmur developing in 
the course of the disease, the patient should not be allowed out of 
bed too soon for fear that unfavorable symptoms may result. 

The temperature is controlled by hydrotherapy. The patient 
is placed in a bath at 100° F. (37.7° C), and the temperature of the 
water gradually reduced to 85° F. (29.4° C). With older children 
the temperature may be lowered still further. Children do not bear 
the classical Brand bath treatment well. The plunge bath is given 
three or four times daily whenever the temperature is 103° F. 
(39.4° C.) or more. Should the child struggle very much against 
the administration of the bath, it is wiser to forego it and sub- 
stitute sponging. If the sponging is not followed by good reaction, 
the use of water should be abandoned. In exceptional cases of 
delirium a bath once or twice daily at 105° F. (40.5° C.) has a 
quieting effect. 

Hemorrhages from the bowel are not frequent in children. They 
may occur early or late in the disease. In the latter case they must 
be differentiated from hemorrhage due to enterocolitis of a post- 



MALARIAL FEVER. 179 

typhoidal character. In hemorrhage due to typhoidal ulcer an ice- 
bag is applied to the abdomen, and small doses of opium, preferably 
the deodorized tincture, are administered to control peristalsis. 
Ergot and digitalis are given internally in order to contract the 
bloodvessels if possible. Enemata should not be given. If the 
hemorrhage becomes excessive, it is proper to give hot saline enemata, 
and to infuse normal saline solution under the skin or into the 
veins. 

Enteritis of an ulcerative or pseudomembranous character occur- 
ring as a complication of typhoid fever is treated in the same manner 
as the primary affection. 

Perforation should be treated on surgical principles. As with 
adults, those perforations which occur late in the disease, when the 
patient is in an exhausted and emaciated condition, give a less 
favorable prognosis than those which occur early. In cases in 
which the diagnosis is doubtful it is best not to operate. 

Constipation. — In most cases of typhoid fever one enema a 
day will remove accumulated feces from the lower bowel. If 
the bowel contents are streaked with blood, enemata should be 
discontinued. In cases in which there is a slight rise of tempera- 
ture during convalescence without apparent cause, grains v (0.3) 
hydrarg. cum creta should be given. Tympanites is treated as in 
the adult subject. The evacuations should be mixed with an equal 
volume of a solution of carbolic acid (1 : 20) as soon as passed. 
The hands of the nurse should be thoroughly cleansed after each 
movement. The patient's hands are cleansed daily, in order to 
avoid auto-infection. 

MALARIAL FEVER. 

Paludism; Malaria; Intermittent Fever.) 

Malarial fever is an acute infectious disease due to the inocula- 
tion of the individual with the Plasmodium malariae. It is common 
in infants and young children, and is believed to occur in utero. 
Crandall has reported a ca>e in which symptoms developed eighteen 
hours after birth, and in which the plasmodium was found in the 
blood of the infant. Those who, like Moncorvo of Brazil, have 
opportunities to observe malarial fever in young infants and children, 
find the greatest frequency under two years. The author has not 
met paludism as frequently in the nursing infant as in older chil- 
dren. The reason for this must lie in the fact that young infants 
nre more protected from infection with veils, etc., than older chil- 
dren. One attack does not confer immunity to subsequent attacks; 
>n the contrary, infants and children once the subject of paludal 
poisoning seem particularly liable to reinfection and relapses. 

The period of incubation varies from a few hours to weeks. In 



180 THE SPECIFIC INFECTIOUS DISEASES. 

the tertian type it is believed to be from seven to fourteen days. In 
one of my eases the first chill appeared eleven days after the patient 
had left the malarious district. 

Etiology. — The essential cause of malarial fever is the same in 
infants and children as in the adult. It is an inoculation fever, 
and is conveyed to the human subject by a certain species of mos- 
quito (Anopheles). The poison exists in the neighborhood of 
swamps and stagnant waters. 

The Parasite. — The plasmodium or protozoa of malaria circulates 
in the blood of infants and children, undergoing its cycle and sporu- 
lation in the same manner as in the adult. In one series of cases 
in infants and children that I studied, the tertian was the most 
prevalent form of parasite. These cases occurred in New York City 
and its vicinity. This has been the experience of other New York 
City observers. One may assume that the blood will, as a rule, con- 
tain the parasite prevalent in a given locality. Several forms of 
parasites may exist in the blood of the same child, or there may 
be several generations of the same plasmodium. These may mature 
at different times, giving various types of fever in the same subject. 
In a tertian case, the fever may thus become quotidian, a second set 
of parasites causing a distinct chill and fever (paroxysm) on the 
day when the first generation is quiescent. We may have, as 
Mannaberg and others pointed out, simple and double tertians and 
quartans. But no combination of quartan parasites can simulate 
the simple tertian type. I have seen very few cases of quartan 
in children. They are uncommon in New York City, but I have 
seen preparations of the quartan type which were found in the blood 
of children in the Southern States. As in adults, tertian paroxysms 
may occur every day, caused by two sets of parasites which mature 
at about the same time daily, or one set matures at a different hour 
than the set of the following day. In such a case paroxysms would 
occur at the same hour only every other day. Many children have 
a distinct severe paroxysm only every other day, but on the inter- 
vening day a careful examination will detect a very low fever. This 
is probably due to a set of parasites which mature without produc- 
ing marked chill or fever (abortive). 

The Blood. — In recent tertian I have found young spores in 
abundance in the blood a few hours after the chill. In some speci- 
mens the spores were free. Between paroxysms in tertian cases the 
blood contains colorless oval plasmodia — the fully developed body — 
leucocytes having rods and pigment-granules and rarely, small round 
forms with flagellar (Koplik). In stained specimens (methyl-blue) 
young native forms are found in all stages up to fully developed 
protozoa. The red blood-cell containing the parasite is distinctly 
enlarged. T nave found in the stained specimen as in the unstained 
ones, the sporula in free groups, bodies with flagellar, and erythro- 



MALARIAL FEVER. 181 

cytes with stained granules. The half-moons are also found in 
chronic cases. The blood contains free granules, and peculiar 
shrunken, brassy-colored, red blood -cells. Monti found the specific 
gravity of the blood to be increased. 

Morbid Anatomy. — Post-mortem examinations in cases of ma- 
larial fever in infants and children are exceedingly rare. Oppor- 
tunity may be afforded when death occurs as the result of accident 
or of some other disease. Monti states that in fatal cases the spleen 
is enlarged; the capsule is tense, and in places shows rupture. The 
pulp is dark red owing to pigment deposit (melanin). Old spleens 
show a disappearance of melanin and a deposit of yellow ochre 
pigment along the trabecule. In chronic cases the connective 
tissue is increased, the liver is enlarged, and there is atrophy of 
die liver-cells. The parasites are found in the blood. The endo- 
thelium of the bloodvessels contains yellow and brown pigment. 
In exceptional cases there are melanin deposits. In acute cases the 
bone-marrow is the seat of melanin deposit ; later this disappears, 
and the marrow is found to be yellow and fatty. The brain cortex 
in severe cases shows pigment deposit ; sometimes there are throm- 
boses and hemorrhages. 

Symptoms. — Children living in malarious districts do not 
always manifest malarial poisoning by having paroxysms of chills 
and fever. The disease is masked under the form of a progressive 
anaemia, with accompanying enlargement of the spleen. These 
patients develop symptoms in from a few days to a few weeks after 
leaving the malarious region. The period of incubation is thus dis- 
tinctly indicated. 

The onset of a paroxysm is usually marked by the appearance 
of chills. In young infants a distinct chill is not always present. 
They become cold and blue at a certain time each day. In older 
children the paroxysm is indicated by headache and a feeling of 
lassitude, which comes on at a certain time each day, or by a 
distinct chill. In exceptional eases eclampsia or vomiting may 
usher in a paroxysm. In other cases there is no eclampsia, but 
the bauds become cold, there is a feeling of faintness, and the 
child complains of being ill. Meanwhile there is a rise of tempera- 
tare, during which there are muscular tremors of the extremities 
and a peculiar upward rolling of the eyes, indicating an impending 
convulsive seizure. The chill may occur during sleep. In one 
case the mother noticed that the child (three years of age) became 
pale during sleep, the hands and extremities became cool, and the 
pulse rapid. The febrile movement following the chill may be very 
-light, scarcely half a degree above the normal. In such cases the 
chill is not marked or i> scarcely noticeable. This occurs in double 
tertian, in which one paroxysm is abortive. In most cases the i'cxvv 
is very high at first — so high that it is characteristic. A tempera- 



182 THE SPECIFIC INFECTIOUS DISEASES. 

fcure of 106.5° F. (41.3° C.) is not uncommon, and is well borne. 
As a rule, the fever has a distinctly intermittent type. The tem- 
perature may rise after the initial chill and remain high for days, and 
then fall to the normal. In the simple form the fever lasts from 
four to twelve hours, and is followed by a critical perspiration, 
during which the temperature rapidly falls to the normal. In some 
cases the children appear free from symptoms in the interval between 
the paroxysms. Others suffer from headaches and a feeling of las- 
situde, and in infants there are gastric and intestinal disturbances. 
In protracted cases a distinct anaemia develops, with progressive 
enlargement of the spleen. Neuralgia of the peripheral nerves has 
been noted in older children. 

During a paroxysm Monti noted polyuria, which persisted until 
the following day. 

The spleen enlarges rapidly, and in a short time may be felt as 
low down as the umbilicus. I have found the spleen markedly 
enlarged ; in one case the organ was not palpable below the ribs, 
although a slight enlargement could be detected on percussion. 

The liver may be enlarged in chronic cases. 

In subacute forms chills are not present, but there is an irregular 
febrile movement, with progressive anaemia and splenic enlargement. 

Repeated Attacks or Relapses. — Children, as well as adults, 
may have repeated attacks of malarial fever. As a rule, however, 
these so-called independent attacks in children are relapses, due 
either to inefficient treatment or to the development of a new series 
of parasites. Infants may have relapses. I have treated such 
.cases until all anaemia and signs of active malarial poisoning had 
disappeared, and then administered arsenic for months, only to 
find a return of the symptoms after an interval of months. 

The diagnosis of malarial fever is based upon an examination 
of the blood. If a child suffers from pronounced anaemia, ma- 
laise, pains in the limbs, and enlarged spleen the blood should be 
carefully examined. Expert knowledge is always necessary for a 
definite diagnosis. It is surprising to note the large number of 
cases beginning with chills and presenting an intermittent fever 
curve and enlarged spleen, diagnosed as malarious, in which parasites 
cannot be detected in the blood. Many septic and inflammatory proc- 
esses in infants and children simulate malaria. Rachitis, syphilis, 
gastro-enteric catarrh, otitis, pneumonia, typhoid fever with relapses, 
have all been mistaken for malarial fever. The diagnosis rests on an 
examination of the blood in all cases in which chills and fever or any 
of the symptoms described coexist with enlargement of the spleen. 

Quinine should not be administered until the blood has been 
very carefully examined. In other words, malaria should be diag- 
nosed or excluded before resorting to this remedy, which was formerly 
much in vogue as a diagnostic test. Its use before diagnosis can 



MALARIAL FEVER. 183 

only result in uncertainty, since there are rises in temperature, not 
due to the paludism, which may be influenced by quinine. A very 
high temperature of an intermittent type, in connection with other 
physical signs, should cause the physician to consider the possibility 
of paludal poisoning. 

I have not seen cases of the pernicious type. They occur in the 
Southern States. 

Acker has recently published 2 cases of malarial fever in children, 
in which there were the initial cerebral symptoms of coma and con- 
vulsions. Coma in one case came on in paroxysms. In the interval 
the child was rational. The sestivo-autumnal parasite (pernicious) 
was found in the blood. 

The prognosis of malarial fever in Xew York City is very good. 
With proper treatment the patient should recover. I have never 
met a fatal case. They occur in districts in which the pernicious 
type of the disease is prevalent. 

Treatment. — If possible, the patient should be removed from 
the malarious district. The remedies employed in all cases are 
quinine and arsenic, or their derivatives. 

According to Golgi, quinine should be given before the par- 
oxysm, and also in the intervals. The action of the drug is exerted 
directly upon the plasmodium. At this time segmentation of the 
parasite takes place in the blood, and most of the young parasites 
are free in the plasma. They then respond most quickly to quinine. 
Large doses should be given to infants and children, in order that 
the infection may be destroyed quickly and completely. The solu- 
ble bisulphate and muriate are suitable preparations. To an infant 
under one year of age grains ij (0.1) are given in a dose, repeated 
three times a day, the last dose being given from three to five hours 
before a paroxysm. To children between two and five years of age 
grains iij to v (0.2 to 0.3) are given in the same manner. Some 
infants take quinine readily when it is suspended in powder form 
in milk or water ; others are given a piece of chocolate, and when 
the surface of the mouth is coated with the candy the drug is admin- 
istered. The syrup of verba santa is also a good menstruum. In 
cases in which children cannot take quinine by mouth, Jacobi 
advises giving it per rectum, dissolving the drug in a solution of 
tartaric acid. I have never been forced to use subcutaneous injec- 
tions of quinine, as the pernicious form of malaria in which this 
mode of therapy is principally resorted to is not prevalent in Xew 
York City. 

Infants and children with chronic or subacute forms of malaria 
are likely to be constipated. Under these conditions I have found 
calomel more efficient in clearing the gut than castor oil. 

After the quinine treatment has been continued for some time 
the spleen will be observed to diminish in size and the paroxysms 



184 THE SPECIFIC INFECTIOUS DISEASES. 

to disappear. If the anaemia persists, it is well, after diminishing: 
the frequency of the dosage of quinine, to combine it with small 
doses of Fowler's solution. The arsenic must occasionally be tem- 
porarily discontinued, or the functions of the stomach will become 
deranged. Warburg's tincture does not seem to be very efficacious 
with children under five years of age, nor with older children, 
unless given in very large doses. Children do not develop cincho- 
nism as quickly as adults, and the quinine may therefore be con- 
tinued for a long time. Treatment should not be suspended until 
the spleen is no longer palpable and the anaemia has disappeared. 
Quinine should then be continued in small doses at regular intervals. 
The preparations of cinchona, such as cinchonidia, cinchonidin, 
chinidin, etc., are not reliable. The following is Baccelli's formula 
for the subcutaneous use of quinine in pernicious intermittent fever : 

Quinin. mnriat 15 grs. (1.0). 

Natrium chlorat 1 gr. (0.06). 

Aq. destillat ^iiss (10.0). 



INFLUENZA. 

(La Grippe ; Acute Catarrhal Fever. ) 

Influenza is a specific infectious disease chiefly affecting the 
mucous membranes. It is highly contagious, although all indi- 
viduals exposed do not contract the disease. It occurs in the form 
of pandemics in which whole communities are affected. This pan- 
demic form occurs less frequently in children than adults, and is of 
interest to the physician only when an epidemic prevails. The 
endemic form of influenza affects children more frequently than 
adults, and is the form which will be described, although in its 
symptoms it closely resembles the epidemic form. The endemic 
form may occur at any season of the year. In large cities influenza 
is always present (endemic), and appears to be more prevalent after 
rapid changes from lower to higher temperatures. Rapid fluctua- 
tions in the humidity of the atmosphere in winter also favor the 
development of the germs of this disease. In New York City, 
midwinter and spring are the seasons when outbreaks of this affec- 
tion occur. 

Age. — Influenza may affect the newly born infant. A case of 
this kind is reported by Townsend in the Transactions of the Ameri- 
can Pediatric Society. The disease is most frequent between the 
ages of six months and five years. The younger the child, the more 
severe the affection. 

Mode of Infection. — Individuals are infected by coming into 
contact with others suffering with the disease. The germ is con- 
tained in the sputum and the nasal secretions ; therefore poorly 



INFLUENZA. 185 

ventilated rooms and public conveyances favor the transmission of 
the disease. Parents may transmit it to their children in the act 
of kissing, and wet-nurses who have la grippe are likely to infect 
the infant at the breast. 

Etiology. — The epidemic form of influenza has been studied by 
Pfeiffer and Kitasato. Pfeiffer isolated a bacillus from the bronchial 
mucous membrane, trachea, and lungs. This bacillus, which is now 
believed to be the essential cause of epidemic influenza, is exceed- 
ingly small, and two or three times as long as it is broad. It has 
rounded extremities, occurs in pairs and chains, does not stain by 
Gram's method, and in influenza, pneumonia, and encephalitis is 
found in enormous numbers in the lungs. It is called the Bacillus 
influenzae. It is still an open question whether it occurs in the 
blood. Although this bacillus has been found in sporadic cases of 
endemic influenza, competent observers, Luzzato among the latest, 
have found that in a large number of endemic cases of influenza 
the Pfeiffer bacillus is absent. Iu its place is found the Frankel 
diplococcus. This is thought to be the essential cause of an im- 
portant group of cases of endemic and sporadic influenza in chil- 
dren — the so-called pneumococcus grippe. Predisposing elements 
in the etiology of endemic influenza are exposure to cold and a 
diminution of the strength of the individual. One attack does not 
protect the individual from subsequent attacks. 

Incubation. — Influenza is believed to have an incubation period 
of from twelve hours to three days. Endemic influenza occurs fre- 
quently in large cities and at times local epidemics of the disease 
are seen. 

Morbid Anatomy. — Inasmuch as influenza is rarely fatal, the 
pathological anatomy is imperfectly formulated. In fatal cases a 
general inflammatory condition of the mucous membrane of the 
nasal passages, and of the larynx and trachea, is found. The sur- 
face of the lining membrane of the bronchi is reddened, covered 
with mucopus, and the membrane itself is infiltrated with small 
round cells. There may be a diffuse inflammation of the smaller 
bronchi, with peribronchitis and inflammatory reaction. Areas of 
bronchopneumonia or lobar pneumonia are found in the lungs. 
The heart is dilated and the seat of myocarditis. There may be 
endocarditis and the kidneys may present an acute nephritis. The 
pleurae arc inflamed, and there may be serous or serofibrinous 
pleurisy or empyema. 

Among the other lesions are those due to the complications, 
otitis, meningitis, inflammation of the gastro-intestinal tract, and 
cerebrospinal meningitis. 

Symptoms. — It has been customary to divide the symptoma- 
tology of endemic influenza as it occurs in children into clinical 
forms. According to my experience, there is no sharp dividing- 



186 



THE SPECIFIC INFECTIOUS DISEASES. 



line between the various forms of endemic influenza as seen in 
children. The gastro-intestinal, nervous, and pneumonic forms are 
frequently present in the same patient. Endemic grippe as it occurs 
in children in New York City will be described, the epidemic or 
pandemic form being ignored. 

The most frequent form is the catarrhal of an acute and 
even subacute type. The infant or child may at the outset have 
a chill. Most frequently there is vomiting, and also fever, and 
pains in the head and limbs. There is a coryza, and in many 
cases a croupy, barking cough. The eyes are injected, the face is 
red and flushed, and the child presents an appearance resembling 
that of the first stage of measles. The mucous membrane of the 
throat is deeply injected and the tonsils inflamed and enlarged. 
The temperature is elevated ; in fact, at the outset it is as high in 
this disease as in malarial fever, 106.5° F. (41.3° C). The cough 
is sometimes incessant. The irritation in the throat is extreme, and 

vomiting after the coughing paroxysm 
may lead the physician to believe that 
he is dealing with whooping-cough. In 
young infants these symptoms may last 
for a day or two, during which the move- 
ments may become green and even diar- 
rheal. This diarrhoea is sometimes so 
severe as to be a prominent feature of 
the disease. The prostration both in 
infants and children is marked. After 
two or three days the catarrhal condition 
of the upper air-passages subsides, and 
the patient develops symptoms of an 
acute bronchitis of a severe type. These 
forms of grippal bronchitis have at the 
outset a high febrile curve (Fig. 42), and 
a fever persisting for days. The bron- 
chitis affects the smallest bronchi. There 
may develop a bronchopneumonia in 
small areas. In other cases the bron- 
chitis passes suddenly into a pneumonia 
without a preceding chill. The pneu- 
Endemic influenza with bronchitis monia of la grippe may be lobular or 

in an infant seven months of age. , . ^ i r ,1 ' u r» 

lobar in type. In the vast majority ot 
cases the pneumonia is of the pneumococcus variety. Especially 
severe are the cases of grippe which are ushered in with a chill, high 
fever, and cerebral symptoms, such as sopor, delirium, and rigidity of 
the neck muscles. In many of these cases examination of the chest 
reveals pneumonia. These cases are not so common among infants 
as among older children. Cases in which there is a cerebrospinal in- 







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INFLUENZA. 



187 



fection in no way differ from cases of cerebrospinal meningitis due to 
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Endemic influenza, lobar pneumonia of the lower lobe of the right lung. Child two and one- 
half years of age. 

with rigidity of the muscles of the neck sots in. Those symptoms 
incrcaso in intensity, sopor finally sotting in with all the symptoms 
of a cerebrospinal meningitis. These cerebral cases are rare. A 
common form of grippal attack is that in which all the symptoms 
of nasopharyngeal inflammation arc present. There is also mild 
bronchitis of the larger tubes. The temperature may fall to the 



188 THE SPECIFIC INFECTIOUS DISEASES. 

normal in the morning or toward noon, but toward evening it rises 
from one-half a degree to three degrees above the normal (Fig. 43). 
The ehild plays in the afebrile intervals. It may awake from sleep 
in a peevish, irritable mood, or may start in its sleep. These symp- 
toms may continue for a week or longer. In many of these cases 
there is serous or purulent otitis media, or there may even be a 
mastoid inflammation from the outset. In other cases the patient 
has an intermittent or remittent fever. The fever, if a continued 
one, has morning or evening remissions. Examination of the heart 
may reveal an acute endocarditis, although marked symptoms of 
cardiac involvement may be absent. 

Symptoms referable to the kidney have received little attention 
in text-books. In endemic grippe there is almost always a slight 
trace of albumin in the urine, which, as a rule, disappears at con- 
valescence. Occasionally, there is a true nephritis, with casts, 
decreased secretion, and blood. Such cases have been described by 
Freeman. Of grave import are the cases of nephritis in endemic 
grippe which at first show a trace of albumin and a few hyaline, 
epithelial, and blood-casts, with a very small (microscopic) amount 
of blood in the urine. The urine is normal in amount. The con- 
dition is revealed only by the microscope. CEdema is absent. The 
child is at first pale, but this pallor disappears later. The trace of 
albumin in the urine, however, with a few casts and blood-cells, 
persists for months. These cases have been described as " cyclic " 
albuminuria. They are really nephritis of an insidious character 
following endemic grippe. 

I have seen cases of endemic grippe complicated with swelling 
of the parotid and submaxillary glands and of the lymph-nodes of 
the neck. 

The duration of endemic grippe is from two or three days to as 
many weeks. I have seen cases present a temperature-curve for 
three weeks, but have not met the cases of protracted duration, with 
or without fever, described by Filatow, and w r ould regard such cases 
as peculiar to the country of that author. 

The prognosis of endemic grippe is favorable. If complications 
supervene, it varies with their nature. 

The diagnosis presents no difficulties. In some cases the ner- 
vous symptoms may cause the physician to suspect meningitis when 
pneumonia is present. A careful physical examination will dispel 
the doubt. Meningitis and pneumonia may be present in the same 
case. Otitis may supervene without the presence of marked symp- 
toms referable to the ear. An aural examination by an expert 
should be made in all cases in which fever persists and physical 
examination of the lungs and other organs fails to reveal abnormal 
conditions. 

The treatment of la grippe is simple. At the outset in the 



GLANDULAR FEVER. 189 

milder cases small doses of quinine are administered, to control the 
headache, restlessness, and fever. For the angina small doses of 
ferric chloride are given to infants every one to three hours. In older 
children, the throat is, in addition, sprayed two or three times daily 
with salt solution or a solution of boric acid or listerine. The fever 
is treated by sponging ; packing or baths are rarely necessary. The 
bowels of infants are washed out with high enemata if diarrhoea 
sets in, and milk food is temporarily suspended. Pneumonia, if 
present, is treated as outlined in the section on that disease. Otitis 
should be treated by early incision of the drum-membrane, as even 
cases in which no pus, but only serum, is present are relieved by 
this procedure. With older children the use of phenacetin alone or 
in combination with monobromate of camphor is permissible if the 
headache and paius in the limbs are very troublesome. A grain 
of each may be given once or twice daily for a short time. The 
prostration is best combated by the use of strychnine alone or com- 
bined with caffeine. Whiskey is not well borne in these cases, since 
it is likely to cause gastro-intestinal symptoms. 



GLANDULAR FEVER. 

(Pfeiffer.) 

Glandular fever is a form of infection which manifests itself by 
an enlargement of the lymph-nodes of the neck, with accompanying 
enlargement of the liver and spleen, and an initial period of fever. 
It occurs from the second to the eighth year of life. During an 
extensive epidemic J. P. West observed it in the nursing infant. 

The etiology is obscure. This disease is a species of infection 
or toxaemia. In some cases (West) there has been diarrhoea, in 
others constipation, and in most cases a slight injection of the naso- 
pharynx. It is possible that the infectious agent gains access to the 
lymph-channels through the gut or nasopharynx. This would 
account for the involvement of the mesenteric glands, as observed 
by Pfeiffer, and for the infection of the nodes of the neck through 
the thoracic duct. 

Symptoms. — After slight malaise, or even without prodromata, 
children are attacked with fever, restlessness, headache, vomiting, 
and pains in the limbs. After a few hours of these premonitory 
symptoms, swelling of the cervical glands on one or both sides is 
noticed. These glandular swellings extend from beneath the 
body of the jaw along and beneath the upper third of the sterno- 
mastoid muscle. The lymph-nodes beneath the muscle are also 
affected. After one or two days these glands or nodes not only 
increase in size, but nodes at the back of the neck and in the supra- 
clavicular region are also affected. In the cases recorded by West 



190 THE SPECIFIC INFECTIOUS DISEASES. 

the axillary and inguinal lymph-nodes were also involved. The 
temperature at first ranges from 102° to 104° F. (38.8° to 40° C), 
but in from twenty-four to forty-eight hours it may fall by crisis. 
There is a slight redness of the pharynx or the color of the mucous 
membrane may be normal. There is pain on deglutition, and there 
may be a slight cough, but no distinct pulmonary affection. In 
both Pfeiffer's and West's cases the liver and spleen were enlarged. 
In the cases of Starck, Rauchfuss, and Protussow these enlarge- 
ments were not always present. 

The lymph-nodes may enlarge to the size of a pigeon's egg. The 
redness of the pharynx is disproportionate to the enlargement of the 
nodes (Pauchfuss), so that it is hardly permissible to speak of an 
anginal lymphadenitis, as in scarlet fever. In both Starck's and 
West's cases there was enlargement of the nodes, which were not 
painful, but sensitive to pressure. The swelling of the carotid 
lymph-nodes began, as a rule, after a few hours, was in most cases 
first visible on the left side of the neck, and reached its height from 
the second to the fourth day. The glands on the opposite side of 
the neck then became affected. The swelling rarely continues uni- 
lateral. It is uniform, as thick as an index-finger (West), and is 
composed of several nodes. There is a stiffness of the neck and 
also a sensation of choking. Suppuration is absent. There is in 
all cases a tenderness of the abdomen about the umbilicus, which, in 
Pfeiffer's opinion, indicates an infection of the mesenteric nodes. 
West found the mesenteric nodes enlarged in 37 cases. 

Diagnosis. — The disease is readily differentiated from mumps. 
In some epidemics the submaxillary glands were involved, but never 
the parotid. The appearance of the swelling of the lymph-nodes 
first on one side, and then on the other side of the neck is character- 
istic, and should be differentiated from the glandular swellings occur- 
ring with grippal affections or pneumonia. Heubner has reported 
cases in which there was a complicating nephritis. 

Duration. — The fever disappears after a few hours or may last 
two or three days. It may recur later. The gandular swellings, 
however, increase or persist nine to twenty-seven days, the average 
duration being sixteen days (West, Pauchfuss). 

Treatment. — As the affection has a tendency to spontaneous 
recovery, the treatment is purely symptomatic. 



CEREBROSPINAL MENINGITIS. 

Cerebrospinal meningitis is an acute infectious disease, of which 
the characteristic lesion is an exudative inflammation of the pia 
mater of the brain and spinal cord. It occurs both epidemically 
and sporadically. 



CEEEBROSPIXAL MENINGITIS. 191 

Etiology. — Cerebrospinal meningitis, both in its epidemic and 
sporadic forms, is due to infection by the Diplocoocus meningitidis 
of Leichtenstern, AVeichselbaum, and Jager. This diplococcus has 
the general form of the gonococcus, is decolorized by the Gram 
stain, and is present in the body of the pus-cell (intracellularis). 
Another group of cases of cerebrospinal type is caused by the Dip- 
lococcus pneumonia?. These cases have been described by Xetter, 
Foa, and Bordoni-Uffreduzzi. They occur epidemically, but gen- 
erally in combination with lobar or bronchopneumonia and as a 
complication of otitis media. The form of affection discussed in 
this section is the sporadic and epidemic cerebrospinal meningitis 
caused by the intracellular diplococcus of Weichselbauin, Jager, and 
Heubner. In epidemics of this disease it is unusual for several 
members of a family to be attacked. The number of cases in an 
epidemic may number several hundred. The disease has no marked 
tendency to spread. In large cities sporadic cases occur in localities 
widely separated. 

Occurrence. — Cerebrospinal meningitis may occur at a very early 
age. Botch reported a case in an infant six days old. The youngest 
case met by the author was in an infant ten weeks of age. Of 
111 cases recorded by Councilman, 29 occurred in infants and chil- 
dren. Males are more frequently attacked than females. Epidemics 
and sporadic cases occur in the winter and early spring. 

Morbid Anatomy. — In certain sporadic cases there are very 
marked symptoms, and yet post-mortem examination will show the 
gross appearances of the brain and pia to be normal. Under the 
microscope, however, a slight infiltration with pus and fibrin and a 
new growth of cells resembling those of the pia are seen. In other 
cases there is an extensive infiltration of the pia with serum, fibrin, 
and pus. The exudation is especially profuse at the base of the 
brain and at the posterior surface of the cord (posterior basic menin- 
gitis). The ventricles are markedly distended with serum and pus 
(Delafield). 

Among the associated lesions found are subserous punctate hem- 
orrhages of the endocardium; petechia? in the skin; hyaline and 
granular degeneration of muscle ; multiple abscesses on the surface of 
the body ; suppuration of the joints; parenchymatous degeneration 
of the heart, liver, and kidneys ; and swelling of the lymph-nodes 
and spleen. In all cases the Diplococcus intracellularis is found in the 
exudate on the pia and surface of the brain and in the ventricular fluid. 

The symptoms in the epidemic and sporadic forms of the dis- 
ease are similar. 

Clinically, the cases which I have observed are divided into three 
distinct types : ". Those in which there is headache, with rigidity 
<>f the neck, fever, and delirium at night, but in which there are 
intervals during which the patients are rational, sit up in bed and 



192 THE SPECIFIC INFECTIOUS DISEASES. 

play with their toys. b. The foudroyant cases, in which death 
supervenes in a short time, the onset with early coma and rigidity 
of the neck and opisthotonos being characteristic, c. The common 
form, beginning with vomiting, headache, and delirium, accompanied 
by rigidity of the neck and stupor. In cases of the last type the 
patients can be roused at intervals. 

The symptoms of invasion are as follows : An infant eight months 
of age develops a conjunctivitis (intracellular diplococcus). After a 
week marked cerebral symptoms — vomiting, convulsions, coma, 
rigidity of the muscles of the neck — appear, with a high febrile 
movement. In other cases there may be a history of a fall. Four 
or five days after the fall (the patient meanwhile attending school) 
headache, vomiting, and difficulty in deglutition set in, and after 
a day or two of these symptoms convulsions manifest themselves, 
with fever and rigidity of the neck. In other cases the onset of 
the disease is signalized by chills, fever, and vomiting, and there is 
occipital and frontal headache. The chills and fever are repeated 
daily, as in intermittent malarial fever. The neck becomes painful 
and rigid, and the patient is dull and apathetic. To these symptoms 
are added delirium and opisthotonos. (Plate IX.). Although the 
modes of invasion differ in certain respects, they resemble each other 
in a general way. In typical cases the symptoms are grouped as 
follows : 

Cerebral Symptoms. — If the fontanelle is not closed, there will 
be tenseness, followed by bulging, even in the early stages, certainly 
by the fifth day. The patients usually have delirium and coma. 
In the milder cases headache is the principal symptom, and periods 
of consciousness alternate with those of stupor. There is hyper- 
esthesia of the surface, and the patients cry out if the bed is jarred 
or the skin touched. In some cases there are chills and convulsions, 
the latter being unilateral. There may be facial paralyses and hemi- 
plegia in the later stages of the disease. 

Reflexes. — The patellar reflex may be absent or exaggerated. 
Babinski's reflex is absent in most cases. Kernig's symptom is 
quite constant. 

The skin may be the seat of successive attacks of erythema. 
Herpes labialis may be present. Tache cerebrale is always present. 

The joints may be tender or swollen. I have never seen suppu- 
ration of the joints. 

There may be intramuscular abscess. 

Eye Symptoms. — I have seen an initial conjunctivitis. In 
Councilman's cases there were keratitis, strabismus, contraction, 
dilatation, and inequality of the pupils, neuritis of varying grades 
of the disc, atrophy, and purulent choroiditis. There is no appre- 
ciable impairment of vision in some cases. In a four months' baby, 
paralysis of the orbital muscles of one side appeared early. 





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193 



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Cerebrospinal meningitis. 
of 



Female child, eight years of age. Temperature at two extremes 
the illness. Recovery. (.Meningococcus.) 



other cases the temperature is persistently high, with remissions of 
a degree or more. On the other hand, an infant nine months of age 
waa affected with cerebrospinal meningitis of the meningococcus 



13 



194 THE SPECIFIC INFECTIOUS DISEASES. 

type, and during a course of two weeks showed no rise of tem- 
perature above the normal. This is, of course, exceptional. Chills 
or rigors are likely to recur in the course of the disease, and are fol- 
lowed by sharp rises in temperature. 

Circulation. — The pulse is rapid and irregular, and the respiration 
as well as the pulse may be increased. Endocarditis, as indicated 
by the presence of murmurs, may exist. 

Paralyses. — Hemiplegia or facial palsy, partial or complete, may 
occur, or there may only be weakness of the upper and lower ex- 
tremities on either side. In the later stages of the disease there is 
incontinence of urine and feces. 

The respirations are shallow but increased in frequency, and are 
also irregular, as will be seen by reference to the accompanying 
charts (Figs. 44 and 45). In some cases Cheyne-Stokes breathing 
is present, owing to cerebral pressure. In other cases this is not 
once apparent during the whole course of the disease. As the end 
approaches, the respirations may cease before the heart ceases to beat 
(ventricular pressure). In the terminal stage the respirations some- 
times fall to 10 a minute and the pulse to 50 with the onset of 
general paralysis. 

In very young infants not only do the fontanelles bulge, but the 
sutures are forced apart, as in hydrocephalus. In cases of this kind, 
on tapping the skull a percussion-wave is felt. Macewen's sign — 
a tympanitic percussion-note over the parietal or frontal bones (see 
page 260) — is also present in cases in which the ventricle is dis- 
tended with fluid. 

The spleen may be enlarged. 

The ear may be the seat of otitis and mastoiditis. Deafness may 
result, and the child may walk with a swaying, tottering motion. 

Blood. — There is leucocytosis at the height of the disease. 

Course and Prognosis. — After symptoms are fully developed 
in typical cases, the patient lies unconscious, the head is retracted, 
and in some cases the back arched. Delirium is constant. The 
neck is rigid. The patient cries out with pain when moved, or even 
when undisturbed. During the rigors the patient becomes cyanosed, 
the heart is feeble, and the respiration shallow and irregular. There 
is always progressive emaciation. In some cases an abortive course 
is described : after headache, fever, and vomiting, convalescence sets 
in and the patient rapidly recovers. Other cases result fatally in a 
few days. Some run a course of from eight to twelve weeks, and 
finally recover. There are few recoveries of children under two 
years of age. According to Hirsch, the average mortality in older 
children is 40 per cent. 

Recovery takes place without complications in some cases, but in 
others various cerebral lesions, such as idiocy, external hydroceph- 
alus, blindness, and palsies, are manifest. 



X 

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POSTERIOR BASIC MENINGITIS. 195 

Diagnosis. — Cerebrospinal meningitis must be differentiated from 
tuberculous meningitis, typhoid fever, and pneumonia with cerebral 
symptoms. 

It can be distinguished from tuberculous meningitis by its sudden 
onset, the presence of the high febrile movement, the early onset of 
rigidity of the neck and opisthotonos, and finally by examination of 
the fluid obtained by lumbar puncture. 

Lumbar Puncture. — In cases of cerebrospinal meningitis this 
should be practised at first as a diagnostic, and subsequently as a 
therapeutic measure. By culture and cover-glass stain the charac- 
teristic intracellular diplococcus will be detected in the fluid with- 
drawn. I have found it present at the fifth and up to the thirty- 
seventh day of the disease. 

In typhoid fever there are the characteristic Widal reaction, leu- 
copamia instead of leucocytosis, and the enlarged spleen. The latter 
sign is of confirmatory value only. 

In pneumonia examination of the lungs will reveal lesions. 
Cerebrospinal meningitis may coexist with pneumonia. 

Posterior Basic Meningitis. 

(Barlow, Lees, Still.) 

Posterior basic meningitis is now by English authors considered 
a form of cerebrospinal meningitis in which the exudate is most 
profuse at the base of the brain. Retraction of the head, marked 
opisthotonos, and emaciation are present early. These cases run a 
protracted course, and the symptoms are those of protracted cerebro- 
spinal meningitis (Plate X.). 

There are other forms of meningitis, due to the pyogenic bacteria, 
the staphylococcus or Streptococcus pyogenes. Thev are not prima rv 
forms of meningitis, but are secondary to otitis, pneumonia, trauma- 
tism, and the infectious diseases, such as scarlet fever and measles. 
If pneumonia exists as a complication, the symptoms are masked 
by those of this disease. The cerebral symptoms in otitis and 
pneumonia may lead to a diagnosis of meningitis. Caution should 
be exercised in making a diagnosis. I have seen cases in which 
rigidity of the head, hyperesthesia, and delirium were present, but 
disappeared rapidly as soon as the otitis was properly treated or 
the pneumonia resolved. If meningitis is confined to the convexity, 
the symptoms in children are similar to those of the adult. If, 
however, a streptococcus, staphylococcus, or pneumococcus menin- 
gitis affects the base of the brain, the symptoms will resemble or be 
identical with those of the cerebrospinal type. Lumbar puncture 
should be performed in all cases of traumatic origin, in order to 
determine the nature of the process present. These forms of si c- 
ondary meningitis are frequently fatal. 



196 THE SPECIFIC INFECTIOUS DISEASES. 

The treatment of cerebrospinal meningitis is symptomatic. The 
hair is cut short and an ice-bag placed on the head to relieve the 
headache and quiet delirium. Allien exudate is present, the patient 
is put on liberal doses of potassium iodide. Infants under a year are 
given grain j or ij (0.06 or 0.12) three or four times daily. The 
delirium is quieted with potassium bromide combined with chloral 
hydrate. The convulsions, as a rule, are not severe, and require 
only ordinary dosage of the bromides and chloral. The bowels are 
kept open by the administration of calomel every few days. The 
fever, as a rule, is not continuously high, and is treated with spong- 
ing. If rigors occur with depression of the heart, warm baths give 
great relief. The patients are put into a bath at 105° F. (40.5° C.) 
for five or ten minutes. The baths not only reduce the tempera- 
ture, but also stimulate the heart. In extreme cardiac weak- 
ness small doses of camphor are indicated. In cases in which 
there are symptoms of cerebral pressure, such as extreme rigidity 
and opisthotonos, coma, delirium, bulging fontanelle, and chills 
and rises of temperature (suppuration), I perform lumbar punct- 
ure. By this procedure the cerebral pressure may be relieved 
for a short time, and the amount of purulent or bacterial exudate 
diminished. About 20 to 50 c.c. are withdrawn. In some cases the 
exudate is so thick and viscid that only a small quantity can be 
drawn off. The flow of fluid should never be aided by an aspirating 
syringe. In the experimental laboratory punctate hemorrhages in 
the medulla and cord have been caused in this way Days should be 
allowed to elapse before the procedure is repeated, and it then should 
be repeated only when there is an exacerbation of symptoms. It 
should be done as early in the disease as possible, and under strict 
antiseptic precautions. When properly performed, no ill results 
follow. 

MUMPS. 

{Epidemic Parotitis.) 

Mumps is an infectious and contagious disease of the parotid 
gland, at times involving the other salivary glands as well as the 
testis or ovary. 

Etiology. — Parotitis is endemic in large cities, and frequently 
becomes epidemic in schools and institutions where large numbers 
of children are congregated. It is most common among children 
of school age, because they are more exposed to infection than 
children at an earlier or later period of life. Girls and boys are 
attacked with the same frequency. It may occur in the newly born 
infant. The author has seen a case in an infant three weeks of age. 

The essential cause of mumps is unknown. Laveran and Catlin 
describe micrococci which they found in the blood and in the glandu- 



MUMPS. 



197 



lar lymph of the parotid and testis. These micrococci were arranged 
in twos and fours, did not stain by the Gram method, and were 
1 to 1.5 micromillimetres in diameter. Michaelis and Bein isolated 
an intracellular chain-forming diplococcus from Steno's duct. The 
theory thus far advanced is that these micro-organisms gain access 
to the parotid through the duct. The period of incubation, according 
to Rilliet and Lombard, may vary from seven to twenty-six days. 

Morbid Anatomy. — As the disease is rarely if ever fatal, 
opportunities to determine the morbid conditions have been few. 
Virchow first described the condition of the Maud as one of in- 
flammatory serous and cellular infiltration of the intra-acinous and 
peri-acinous connective tissue. The outcome is resolution ; indura- 
tion rarely remains. 

Symptoms. — There is a prodromal period, during which the 
patient is attacked with chilly sensations or a chill, and sometimes 



Fig. 46. 




Parotitis, bilateral. Boy, six years of age. 

with vomiting. There is pain in the region of the ear, and also a 
ringing in the ears and deafness. There is also a febrile move- 
ment, the temperature in some cases mounting to 104° F. (40° C). 
The temperature may be normal throughout the disease. There may 
be headache and loss of appetite. After these symptoms have lasted 
awhile, the face becomes swollen, as a rule on one side only (Fig. 46). 



198 



THE SPECIFIC INFECTIOUS DISEASES. 



This swelling gives the face an uneven contour, and is the charac- 
teristic symptom. In older children it causes a feeling of tenseness 
and pain on mastication. Sometimes patients are averse to opening 
the mouth on account of the pain. In young infants there is drool- 
ing. In the majority of cases, after the swelling has lasted three 
or four days and is subsiding, the opposite side becomes affected. 
In addition to the swelling of the parotid there is also intumescence 
of the lymph-nodes of the neck at the angle of the jaw and of the 
node on the parotid gland in front of the ear. Frequently the sub- 
maxillary glands are also swollen, giving the whole face a rounded 



Fig. 47. 




■0, 


: 


r 

V 






Parotitis involving the submaxillary glands, lateral view. Boy, four years of age. 

contour. In most cases the general condition of the patients is good 
and there is very little discomfort. Other cases have considerable 
pain and constitutional disturbance. In all my cases there was 
distinct angina and swelling of the tonsils. In a newly born baby 
there was swelling of the tissues underneath the jaw and about the 
larynx, with croupy breathing indicating oedema of the mucous 
membrane of the larynx. 

English authors have described cases in which the submaxillary 
glands alone were involved, the inflammation being strictly limited 
to the glands on both sides (Fig. 47). I have seen a few cases of 
this kind. 



MUMPS. 



199 



Complications. — The testes and epididymis in boys and the 
ovaries and glands of Bartholin] in girls may become affected. There 
may be ardor nrinse and a urethral discharge. These complications 
are not so common as the text-books declare. Hydrocele may 
occur with the orchitis. I have seen a case of this kind in a verv 
young infant. The urine may show a trace of albumin, or in 
very rare eases there may be blood in the urine. ' Endocarditis, 
pericarditis, rheumatism, and osteomyelitis have been reported as 
complications, but the author has never met such cases. Parotitis 
complicating pneumonia has been observed in a boy of six years, 
and in another case otitis and parotitis were present at the same 
time. In rare eases the breasts and lachrymal glands are affected. 
Parotitis may be a complication of typhoid fever, measles, varicella, 
and influenza. 

Course. — The disease is at its height in from three to six days, 
and runs its course in from seven to fourteen days. Mild cases may 



Fig. 48. 

., 4 IPw 




^^Kf ^ 






v vi "if 



Angioma of the parotid simulating n 



last only two days. Severe cases are rare. These present cerebral 
symptoms, and -welling of the tissues about the neck simulating 
angina Lndoviei, with considerable dyspnoea. Cases of recurrent 
mumps, continuing for from four to six week-, are recorded. When 
suppuration occurs, it is probably the result of some mixed infection. 



200 THE SPECIFIC INFECTIOUS DISEASES. 

The diagnosis is not difficult. Uncertainty as to whether the 
parotid is affected or not will be dispelled by drawing a line parallel 
with the lower border of the jaw ; the parotid swelling will be above 
the line and the lymph-nodes of the neck below it (Fig. 46). In 
swelling of the mastoid region the ear is raised from the skull, while 
in parotid swelling, even if it occur behind the ear, that organ 
remains in its normal position. The swelling of parotitis never fluc- 
tuates, but is elastic in character. 

The prognosis of mumps is good ; the majority of cases recover 
without complications. If the kidneys and endocardium and peri- 
cardium are affected, the prognosis will be influenced by the course of 
these affections. I have never known epidemic parotitis to result 
fatally. 

Treatment. — The patients are isolated and kept in bed as long 
as symptoms are present. The parotid is anointed twice daily with 
warm oil of hyoscyamus and covered with cotton. The bowels 
should be regulated with a saline cathartic. The diet should be 
assimilable. The affection cannot be controlled by means of drugs. 
Pain and fever are treated on general principles. 

PERTUSSIS CONVULSIVA. 

( Whooping-cough.) 

Pertussis is an acute specific infectious disease, caused by a micro- 
organism, probably of the influenza group. It is characterized in 
the majority of cases by a spasmodic cough accompanied by a so- 
called whoop. 

Pertussis is not only infectious, but it is also contagious. It is 
propagated through the atmosphere in schools and public places, the 
air of which is contaminated with the specific agent of the disease. 
The micro-organism is thought to exist in the sputum and the secre- 
tions of the nasal and air-passages of the patient. The disease is 
especially contagious at the height of the attack. There is reason 
to believe that the cough of the first or catarrhal stage is highly 
contagious. The sputum in the stage of decline is also, in my 
opinion, capable of conveying the disease to others, since it contains 
the specific micro-organism. 

Occurrence. — Pertussis prevails in all countries and climates. 
It is most frequent during the winter and spring months. It is 
always endemic in large cities, but, like scarlet fever, becomes at 
times so prevalent as to be epidemic. Pertussis is essentially a dis- 
ease of infancy and childhood, but the individual is not exempt at 
any age. It has been seen in the newly born infant. I have 
found the disease slightly more frequent in females than in males 
(1009 out of 1820 cases). Twenty-two cases occurred in infants 
between one and two months of age. The majority of cases (1343) 



PERTUSSIS COXVULSIVA. 201 

occurred between the sixth month and the fifth year. The disease 
is most frequent between the first and the second year (404) ; 
next most frequent between the sixth and twelfth month. After 
the fifth year the frequency diminishes up to the tenth year, after 
which the disease is very infrequent. Not every one who is exposed 
contracts the disease. One attack does not necesarily confer im- 
munity, but cases of second attack are rare. It has been observed 
that pertussis, measles, and influenza frequently follow one another 
in epidemic form. 

Etiology and Bacteriology. — The essential cause of pertussis 
was believed by Deichler and Kurloff to be a protozoa-like body 
which they found in the sputum. Afanassjew and Szemetzchenko 
isolated a bacillus from the sputum. It occurred singly, in pairs 
or chains, and measured 0.6 to 2.2 micromillimetres in length. The 
more recent researches on the bacteriology of pertussis are those 
of Czapelewski, Hensel, and Koplik. Czapelewski and Hensel 
described in 1897 a non-motile "pole bacterium " or bacillus 
resembling the influenza bacillus. I at the same time described 
in the sputum a finely punctate, thin, minute bacillus, 0.8 to 1.7 
micromillimetres in length, resembling the influenza bacillus, and 
staining like that or like the diphtheria bacillus. This bacillus was 
found recently by Luzatto in cases occurring in an epidemic of per- 
tussis in the city of Graz. It is classified by him as belonging to 
the influenza group. Positive proof that this bacillus is the cause 
of pertussis is lacking, since the disease has not as yet been pro- 
duced experimentally. Evidence simply points toward a bacillus 
of the influenza group constantly found in the sputum. 

Morbid Anatomy. — Post-mortem examination reveals marked 
inflammation of the nasal passages, bronchopneumonia, and empyema 
or simple fibrinous or serous pleurisy. Emphysema as a result of 
rupture of the lung-tissues lias been reported by Xorthrup, who 
describes the lungs of an infant seven months old as being studded 
with cavities measuring one-half a centimetre to two centimetres in 
diameter. The lungs looked like parchment filled with bubbles. 
Hemorrhages in the eye, ear, and brain are a feature of the morbid 
anatomy of fatal cases. 

Symptoms. — There is undoubtedly a period of incubation, but 
its length is undetermined, and it can only be said that, if the dis- 
ease is due to the invasion of a micro-organism, some time must 
elapse between the invasion and appearance of symptoms. After the 
appearance of the symptoms there are three stages — the catarrhal, 
the spasmodic, and the stage of decline. There is no sharp line 
of demarcation between these stages. 

Catarrhal Stage. — This stage in some children is characterized by 
a cough which is especially troublesome at night, and has sometimes 
a croupy character. The peculiar nature of the cough becomes ap- 



202 THE SPECIFIC INFECTIOUS DISEASES 

parent when after a few days it becomes more troublesome instead 
of subsiding. After four or five days it may be accompanied by 
vomiting once or twice a day, especially if the paroxysm occurs 
after meals. Examination of the chest may fail to reveal bronchitis. 
This negative sign is of great value. As the case passes into the 
spasmodic stage it is noticed that the paroxysms of coughing last 
longer, and that the child becomes red in the face and expectorates 
a larger amount of mucus than in ordinary catarrhal conditions. 
This period of cough without a whoop may last five to twelve 
days. I have seen many cases in which the whoop was absent in 
the whole course of the affection. The child had what might be 
regarded as a severe spasmodic cough followed by vomiting. Fever 
is present as a rule only during the first few days. It may be re- 
mittent and slight. If bronchitis complicates this stage of the dis- 
ease, there may be a daily rise of one or more degrees in temperature. 
Usually toward the close of the catarrhal stage the incessant cough 
causes slight puffiness of the eyelids and slight oedema of the tissues 
of the face. 

The spasmodic stage is distinguished by the presence of the char- 
acteristic whoop. The cough becomes of a more pronounced spas- 
modic type. The child has distinct paroxysms, which begin with 
an inspiration, followed by several expulsive explosive coughs, after 
which there is a deep, long-drawn inspiration, which is characterized 
by a loud crowing called the whoop. After one paroxysm has 
ended, it may be followed by a number of similar ones. When a 
paroxysm is impending the face assumes an anxious expression, 
and the child runs to the nearest person or to some article of furni- 
ture and grasps it with both hands. The paroxysm is sometimes 
so severe that the child will fall prostrate or claw the air convul- 
sively. In the severest and most dangerous type a convulsion 
supervenes. In moderately severe types of the disease the child's 
face is red or livid, the eyes bulge, and at the end of the paroxysm 
a quantity of tenacious mucoid or mucopurulent sputum is expecto- 
rated. In other cases there is vomiting at the end of the paroxysm. 
In the intervals the face is livid or pale, or the eyelids are puffy 
and the face eedematous. In some cases there are punctate hemor- 
rhages on the face, especially about the eyes and temples. There 
may be chemosis of the conjunctivae as a result of the bursting of 
bloodvessels. At this period there is in the majority of cases an 
accompanying bronchitis, with slight rise of temperature during the 
day. At first the paroxysms occurring during the twenty-four hours 
may be few ; in some cases they never become frequent, but as 
a rule they increase in number, so that the patient may have from 
twenty to one hundred in the twenty-four hours. This stage grad- 
ually declines, the number of paroxysms diminishing daily in num- 
ber and severity. They may subside suddenly or gradually after 



PERTUSSIS CONVULSIVA. 



203 



from four to twelve weeks. The whoop may at times reappear. 
After the disappearance of the whoop a cough persists for days or 
even weeks, or it may entirely disappear and suddenly recur with 
the whoop. It is characteristic of the spasmodic period of the dis- 
ease that the paroxysms should be more harassing at night than 
during the day. 

Other Symptoms. — In all cases of pertussis, even in the absence 
of complications, there is a slight increase in the number of respi- 
rations. In cases of even moderate severity the heart impulse 
is weak, and in exceptional cases the area of superficial cardiac dul- 
ness is larger than normal, indicating dilatation of a moderate 
degree. The pulse is irregular in force and rhythm, and is dis- 
tinctly more dicrotic than normal. In other words, there is a con- 
dition of heart-strain, which is evinced by dyspnoea (even in the 
absence of exertion), oedema of the face, and cyanosis. 

Kidneys. — In the majority of cases a trace of albumin is present 
in the urine ; in others, a few hyaline casts. Blood in the urine 
is seen in rare cases. 

Blood. — Leucocytosis of the polynuclear type is usually present 
in the second week of the disease. 

Complications. — One of the most common complications of 
pertussis is bronchitis. It may be mild or severe. In the severer 



















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Pertussis; disseminated bronchopneumonia in both lungs. Infant eight months of age. 

Fatal termination. 



form the smaller bronchi are affected, with accompanying broncho- 
pneumonia (Fig. 49). The physical signs arc the same as in simple 
bronchitis and pneumonia without pertussis. In some cases the 
bronchopneumonia pursues a subacute or persistent course. If reso- 



204 THE SPECIFIC INFECTIOUS DISEASES. 

lution takes place, other areas become consolidated. Emaciation is 
sometimes extreme. Emphysema is frequently present. Bursting 
of the air-vesicles may cause pneumothorax, or air may escape into 
the mediastinum and thence into the neck and into the subcutaneous 
tissue of the whole trunk. 

Hemorrhages. — During a paroxysm there may be epistaxis, con- 
junctival hemorrhage, bleeding from the ears, and petechia? on the 
face and body. 

Nervous System. — Convulsions, either general or localized, may 
complicate pertussis. In the former case the outlook is grave, 
death usually taking place within twenty-four to forty-eight hours. 

Psychoses, such as melancholia and hallucinations, may compli- 
cate pertussis. Monoplegia, hemiplegia, or paraplegia, localized facial 
and oculomotor paralyses, sudden total blindness, deafness, cerebral 
hemorrhages, hemianesthesia, and aphasia have been observed. 

Gastro-enteritis of a fatal type may ensue. 

An attack of pertussis may favor the invasion of the tubercle 
bacillus. This may have been previously present in the bronchial 
lymph-nodes or elsewhere in the body, or it may be received into the 
body during the attack or afterward. In such cases tuberculosis of 
the lung or other organs, such as the peritoneum, develops. 

Diagnosis. — If a cough fails to improve and is especially harass- 
ing at night, later in the disease becoming paroxysmal, if the face 
becomes livid during the paroxysm, if the patient vomits after 
coughing, pertussis should be suspected and precautions taken to 
prevent its spread. As a rule, examination of the chest is nega- 
tive in the first stage. The absence of bronchitis and the presence 
of a cough of the character described, are characteristic of pertussis. 
The presence of the whoop dispels all doubt. 

Infants who have the incisor teeth and other children may, after 
the pertussis has lasted for a week, develop an ulceration of the 
frenum of the tongue, which is called a dentition ulcer. It is caused 
by friction of the frsenum lingua? with the edges of the teeth during 
the act of coughing. These ulcerations are not diagnostic of the 
disease ; many cases do not show them, and on the other hand they 
frequently occur in coughs of other forms. 

Mortality and Prognosis. — The mortality of pertussis is greatest 
during the first year of life (25 per cent., Voit). Between the first 
and the fifth year it is about 5 per cent., and from this time to the 
tenth year, 1 per cent. (Monti). The occurrence of pneumonia in 
children under two years of age adds largely to the mortality. 
Rachitis or marasmus will militate against recovery. Hygienic sur- 
roundings render the prognosis more favorable. 

Treatment. — Prophylaxis. — The patient should be isolated, and 
should sleep in a large, well-ventilated room. During the day the 
sleeping-room may be filled for an hour with the vapor of formalin 



PERTUSSIS CONVULSIVA. 205 

(set free by means of a .small formalin lamp). The object is to 
destroy suspended germs. If two communicating rooms are avail- 
able, they may be occupied alternately every twenty -four hours, the 
unoccupied room being fully ventilated in the interval. In this 
way reinfection may be avoided. 

In spring and summer, if the weather is favorable, the children 
should be constantly in the open air during the day. In large cities 
the mother is directed to take the child into the park. When in the 
open air the paroxysms are usually notably lessened. The child 
should be warmly clad in winter. Sea air seems to aggravate some 
cases and benefit others. Pine woods and moderately high altitudes 
are probably the most beneficial, for the patients are not exposed to 
the unfavorable climatic conditions peculiar to the seacoast. 

Medicinal treatment consists of inhalations, topical applications, 
and internal remedies. Simply to enumerate all the remedies which 
have been proposed and used in pertussis, would take up the 
space of a monograph. Inhalation of ozone has been advocated by 
Caille. The remedy is expensive and the apparatus not readily 
procurable. Inhalation of a mixture of 20 per cent, nitrous oxide 
and 80 per cent, oxygen is beneficial in cases in which the heart is 
weak. The inhalations are given with a cone for ten minutes twice 
daily. Insufflation of quinine or other drugs has not proved bene- 
ficial. The practice seemed to intensify the paroxysms. Prior, 
Coggeshall,and others have proposed the application of solutions of 
cocaine, 4 per cent, to 10 per cent., to the nares and throat. I have 
had no experience with this method, nor with the local application 
of antitussin. 

If the cough is very troublesome, I first endeavor to control it 
with full doses of antipyrin combined with tincture of digitalis. 
The digitalis, in doses of a drop or two several times daily, supports 
the heart, as is shown by the rapid disappearance of the oedema and 
cyanosis after its administration. Antipyrin is given in doses of 
grain j (0.06) for every year of age up to grains v (0.3) every three 
hours. If the cough is not perceptibly relieved by this remedy after 
forty-eight hours, I suspend its use, and give codeine in full doses 
every three hours. Codeine is to be preferred to morphine, which is 
advocated by Henoch. If vomiting is severe, the food is given in very 
small quantities in fluid form every few hours. By this method food 
is retained and absorbed, whereas a full meal is invariably rejected. 
The use of belladonna has not impressed me favorably. In several 
cases it seemed to aggravate the cough by drying the laryngeal 
mucous membrane. Bromoform 1 consider dangerous and of <|iies- 
tionable utility. Quinine in full doses three or four times daily is 
a favorite remedy with many pediatrists. Vaccination and the 
injection of diphtheria serum have been proposed to abort the dis- 
ease. I have had no experience witli the serum treatment. In a 



20li THE SPECIFIC INFECTIOUS DISEASES. 

word, the treatment of pertussis consists in applying the rules of 
hygiene, in mitigating the cough with antipyrin or preferably 
codeine, and in supporting the heart with digitalis. The compli- 
cations should be treated on the principles laid down in the sections 
on Bronchitis, Pneumonia, and Pleurisy. 

DIPHTHERIA. 

Diphtheria is a contagious febrile disease which affects the throat 
and air-passages. It is characterized by the formation of a pseudo- 
membrane on the parts affected. The disease manifests itself by a 
local lesion and general symptoms caused by the entrance of toxins 
and, at times, of bacteria into the blood and lymph. 

Age and Occurrence. — Although diphtheria is uncommon in 
the newly born infant, statistics of large numbers of cases show a 
certain percentage in these subjects ; thus, of 547 cases reported by 
Monti, the newly born number 24, and in Baginsky's statistics 
several cases are noted. The disease is more frequent from the first 
to the third month than from the third to the tenth month (Monti). 
The largest number of cases occur from the second to the sixth 
year (40 to 63 per cent.) (Monti, Baginsky). 

According to Seitz, it is slightly more frequent among boys than 
girls. Strong as well as weakly children are attacked. Children 
who suffer from nervous affections, such as poliomyelitis, are more 
likely to contract the disease than others (Baginsky). All exposed 
to infection do not contract the disease, because some individuals are 
immune. Escherich and Fischl have proved that the blood of con- 
valescents contains antitoxic elements. Cases of several attacks in 
the same individual are not uncommon. Racial peculiarities have 
no influence. 

Diphtheria is prevalent in all parts of the world and epidemics 
occur at all seasons of the year. It is more common among the 
poorer classes, not on account of uncleanliness, but as a result of 
overcrowding. 

Contagion. — Diphtheria is contagious from person to person, 
and may be conveyed by any one w T ho has been in the room occu- 
pied by a patient with the disease. Mild cases may give rise to fatal 
cases. The disease is infectious, spreading through families and 
schools, and may be conveyed through the medium of toys, clothes, 
and in milk. 

Etiology. — The essential cause of diphtheria is a bacillus, the 
Bacillus diphtheria?, which was first noted in stained specimens 
by Klebs in 1882. Loffler first isolated and accurately described 
it in 1884. It is present in all cases of true diphtheria of 
Bretonneau. In the 3 per cent, of cases in which it is reported 
absent there is good reason to believe that failure to establish its 



DIPHTHERIA. 



207 



presence was due to imperfect technique. The bacillus is non -motile, 
twice as thick and about as long as the tubercle bacillus, thickened 
at the extremities, has no spores, and in some forms has been de- 
scribed as branching. It is very resistant, adheres to clothes and 
candy, and has been found in milk. It will retain vitality a long 
time in dried membrane (seventeen weeks), as has been shown by 
Roux and Yersin. It has been detected nine weeks after the disap- 
pearance of the membrane from the throat. It is found present with 
other bacteria, principally staphylococci and streptococci, pneumo- 
cocci, Bacillus coli commune, pyocyaneus, proteus, and sprue. It has 
been found by Roux and Yersin in the throats of perfectly healthy 



Fig. 50. 



Fig. 51. 




The Bacillus diphtherise (Klebs-Loffler). 
Fig. 50.— Pure culture, photomicrograph. Fig. 51.— Pure culture, photomicrograph. 

X 1000. X 1000. Shows the irregular beaded stain. 



individuals, and may be present without the formation of a mem- 
brane. It has been shown that this bacillus forms toxins of very 
positive action. According to Sidney, the toxins of diphtheria may 
be divided into albuminoses and organic acids. 

The pseudobacillus of diphtheria was first isolated by Hoffman. 
In its growth and staining properties it is identical with the true 
diphtheria bacillus, but is not virulent to animals. Roux and Yersirj 
regard it as a weakened diphtheria bacillus. Others believe that it 
bears no relation to the true bacillus. It is found associated with 
the true bacillus, and also in <•;)-<- of diphtheria after this bacillus 
has disappeared from the throat (Koplik). Some authors have 



208 



THE SPECIFIC INFECTIOUS DISEASES. 



given the name pseudodiphtheria bacillus to another variety of 
bacilli, but this term should be strictly limited to the form described 
above. 

General Infection with the Bacillus Diphtheria alone and with Other 
Bacteria. The bacillus of diphtheria was first demonstrated by Frosch 
(1895) in the heart's blood, liver, spleen, kidneys, and lymph-nodes. 
Since then, Kolisko, Paltauf, Schmorl, Booker, Councilman, Mallory, 
and Wright have demonstrated its presence in the blood and internal 




1 and 3. Cultures of the pseudo-bacillus of diphtheria on agar, showing the diffuse char- 
acter of the growth. 2. Growth of Bacillus diphtherias (Klebs-Loffler) on the same medium. 
It is a delicate growth in colonies. 

organs in fatal cases of diphtheria. The work of Councilman and 
his pupils is the most recent and complete on this subject. They 
show that the bacillus may occur alone or in association with strep- 
tococci or staphylococci in the blood, lungs, liver, spleen, and kidney. 
It is more likely to be found alone in fatal cases of uncomplicated 
diphtheria. The mixed infections with streptococci and other bac- 
teria occur in diseases, such as scarlet fever and measles, which may 
be complicated with diphtheria. The investigators just mentioned 
found endocarditis, bronchopneumonia, empyema, mastoid disease, 



DIPHTHERIA. 209 

and thrombosis of the sinuses due to the diphtheria bacillus. The 
bacillus was found also in the pus of acute abscesses in various 
localities. 

Morbid Anatomy. — In fatal cases the membrane appears as a 
thick brownish or grayish-brown mass. It is sometimes present as a 
thin whitish pellicle, and occasionally is almost black. It may be 
friable or as resistant as cartilage, and may extend over the tonsils, 
palate, pharynx, base of tongue, epiglottis, and trachea. The areas 
not covered by membrane are injected, and may be the seat of hemor- 
rhages. The tonsils are enlarged and bluish red. In the gan- 
grenous forms the tonsils, soft palate, and uvula may be converted 
into necrotic masses. The nasal passages may show membranous 
deposit. The epiglottis and vocal cords are thickened. The tracheal 
mucous membrane is hyperaemic and swollen, there may be adherent 
membrane, or the pseudomembrane may be loose and curled up in 
the lumen of the trachea. 

The membrane itself has been described by Virchow as croupous 
and diphtheritic. Councilman is of the opinion that little is to be 
gained by adhering to the old classification of croupous and diph- 
theritic membranes. Baginsky also describes forms of diphtheria in 
which the membrane possessed both croupous and diphtheritic struct- 
ural characteristics. According to Councilman, the first step in the 
formation of the membrane is a degeneration and necrosis of epithe- 
lium, preceded by a proliferation of the nuclei of the cells. Detritus 
and hyaline masses result. An inflammatory exudate rich in fibrin is 
thrown out from the underlying tissue. The fibrin forms in part a 
reticulum enclosing cells and degenerated epithelium, and in part a 
hyaline reticulated membrane. The hyaline membrane is formed on 
surfaces which are covered with several layers of epithelial cells. 
Fibrinous membrane is formed on the surface and in the tissue. By 
constant accretions thick masses are formed. The membrane is never 
formed on an intact epithelium, but may extend over it. There is 
nothing specific in the diphtheritic membrane. The connective tissue 
and the bloodvessels beneath the membrane may be the seat of hya- 
line degeneration. The mucous glands are degenerated. 

The diphtheria bacilli are found growing in the necrotic tissue 
and in the exudation, never in the living tissue or in epithelium 
undergoing primary degenerative changes. In exceptional cases 
they may be found enclosed in pus-cells and necrotic epithelium. 
They are found in masse-, and when deeply situated have been 
covered up by later formation of membrane. 

Heart. — Councilman, Mallory, and Pearce have recently described 
the myocarditis sometimes complicating diphtheria. There is a fatty 
change in foci or in more diffuse areas in the muscle-fibre. In 
another form of myocarditis then' are interstitial changes, consisting 
of focal collections of plasma and lymphoid cells, and the forma- 
u 



210 THE SPECIFIC INFECTIOUS DISEASES. 

tion of new connective tissue, resulting in some cases in a fibrous 
myocarditis. These pathologic changes are due to the action of the 
diphtheria toxins on the heart-muscle. 

The Lungs. — Councilman states that the most common lesion in 
fatal cases is a bronchopneumonia, lobar pneumonia never being 
present. The process begins in an infection of the atria. The bac- 
teria found in the lung, and which are present independently of the 
character of the lesion, are the pneumococcus (rarely), Streptococcus 
pyogenes, and the diphtheria bacillus. Marrow-cells are found in the 
capillaries, and thrombi in the larger vessels. The lymphatics are 
dilated and contain fibrin and cells. 

The spleen macroscopically is normal ; microscopically, the 
lymph-nodules are more prominent than is normal, and contain foci 
of epithelioid cells. The vessels are the seat of hyaline degenera- 
tion, and in the later stages contain large numbers of plasma-cells. 
Some of the nodes may be the seat of necrosis and abscess. 

Liver. — The changes in this viscus are due to the action of toxins, 
and consist of parenchymatous degeneration and necroses, seen 
especially in the centre of the lobules. There is slight hyaline de- 
generation of the capillaries. 

Kidneys. — There may be simple degeneration or acute nephritis. 
The severe forms of nephritis are found in the cases which are 
quickly fatal (Councilman). The interstitial and glomerular changes 
are more common in older children and in protracted cases. There 
is no specific form of nephritis in diphtheria, and all the changes are 
due to the action of toxins. 

Lymph-nodes. — The mesenteric lymph-nodes, the nodes at the angle 
of the jaw and in the retropharynx and oesophagus are enlarged, and 
may undergo necrotic changes (Flexner). Councilman, Mallory, 
and Pearce describe the changes in the lymph-nodes as being more 
marked in those nearest the lesion. There are congestion, hemor- 
rhages, and diffuse and circumscribed necrosis. In addition there is 
a formation of foci resembling miliary tubercles, and composed of 
epithelioid cells which undergo degeneration, forming granular de- 
tritus. Bacteria are not found in the nodes. The changes are due 
to the toxins. 

Nerves. — There are fibrillation, increase of the cells of the sheath 
of Schwann, fatty degeneration of the axis-cylinder, hemorrhages, 
and nodular degeneration of the nerve-sheaths. In the spine there 
are infiltration, of the meninges, hemorrhages, and degeneration of 
the anterior horns. Degenerative oculomotor changes are present. 
There are dilatation and round-cell infiltration around the central 
canal of the cord. 

Stomach. — Diphtheritic membrane in the stomach occurring in 
eases of diphtheria has been described by Smirnow and Council- 
man. Of '220 cases reported by the latter, 5 showed the pres- 



PLATE XI 






GrDupuy 



1. Tonsillar Diphtheria, with a small patch of membrane 

on the uvula. 

2. Tonsillar Diphtheria, with a patch of membrane on the 

pillars of the fauces. 

3. Acute Follicular Amygdalitis, which may be diphtheritic. 



DIPHTHERIA. 211 

ence of membrane to a greater or less extent. The membrane 
either covered the whole surface or formed patches or streaks over 
the rugae. The mucous membrane was swollen, hyperaemic, or 
hemorrhagic. 

The Middle Ear. — Of 144 cases reported by Councilman, Mal- 
lory, and Pearce, 8b* showed involvement of the middle ear on one 
or both sides ; in 7 the mastoid was affected. The inflammatory 
products Mere serum or pus. The organism most constantly present 
was the streptococcus, but the diphtheria bacillus has been found, as 
have also the staphylococcus and pneumococcus. 

The Blood. — The specific gravity is increased at the height of the 
disease. In mild eases it is not perceptibly changed ; in severe 
septic cases it may range from 1054 to 1060 (Baginsky). Haemo- 
globin is reduced only in severe case- of protracted course. Leuco- 
cytosis is not marked in mild cases, but in severe septic forms an 
increase of the white blood-cells has been observed by Felsenthal 
and Monti. In malignant cases there is a reduction in the number 
of red blood-cells (Ewing, Billings, Morse). 

Symptoms. — Clinically, it is convenient to divide diphtheria 
into the purely local forms with few constitutional symptoms, the 
local forms with symptoms of marked toxaemia or septic forms, and 
the laryngeal forms. 

Purely Local Forms with Slight Constitutional Disturbances. — In 
diphtheria sine membrana, synanche contagiosa (Senator), or catar- 
rhal diphtheria, there may be no formation of membrane, the fauces 
showing only an angina of varying severity. In some cases there is 
the picture of a follicular or lacunar amygdalitis. Macroscopicallv 
there is nothing to show that the process is diphtheritic (Plate 
XL). In other forms the membrane is present on the tonsils as 
specks or strips of exudate, or white or greenish pultaceous masses 
which may extend to the uvula, or there may be spots or extensive 
plaques on the posterior pharyngeal wall. In other mild cases the 
process is confined to a small necrotic excavated area in one or the 
other tonsil, as described by Henoch. In still other forms the 
membrane may vnwv both tonsils, and extend over the soft palate 
and pillars of the fauces. In these forms of localized diphtheria 
the nares are seldom involved. 

In these localized forms of diphtheria the infant or child may 
present few symptoms pointing to the throat affection. Unless the 
physician be systematic in his methods of examination, he may fail 
to inspect the throat at his first visit, and the diphtheria may thus 
escape detection. The nursling in this as in the non-diphtheritic 
affection, may refuse to take the breast. The movements are green- 
ish, and have an offensive odor, or may be diarrhoeal. There are 
fever and restlessness. [nspection will reveal slight or marked 
swelling of the lymph-node- at the angle of the jaw. 'flic temper- 



212 THE SPECIFIC INFECTIOUS DISEASES. 

ature may not be above 101° F. (38.3° C.) or may be as high as 
105° F. (40.5° C). As a rule, it is not persistently high. The 
pulse is accelerated and the respirations slightly increased. The 
invasion of the disease is for the most part insidious in nurslings ; 
rarely is there a chill or convulsion. The tonsils are enlarged, and 
show small specks or plaques of membrane on their surface. The 
uvula may be red and swollen, and there may be patches of mem- 
brane on the sides adjacent to the tonsils. There is sometimes a 
croupy cough. In purely local diphtheria, however, the larynx is 
not involved in the majority of cases. The urine may show a trace 
of albumin, and in some cases a few leucocytes, blood-cells, and a 
very few hyaline casts. In older children the signs of illness are 
more marked. They complain of pain on swallowing, and the 
temperature may at first be high. Toxsemic symptoms, such as pain 
in the joints, headache, pain in the back, and slight prostration, are 
present. Inspection of the throat may show the tonsils to be enlarged, 
and to present the appearances mentioned above. Other members of 
the family may complain of sore throat. I have reported cases in 
which children complained of but few symptoms and engaged in their 
customary play. Examination of their throats disclosed the presence 
of simple inflammatory redness and swelling of the tonsil, pharynx, 
and uvula. In these cases the diphtheria bacillus was detected in 
scrapings from the fauces. Membrane never developed, and yet 
they were cases of true diphtheria. 

The fever is not characteristic. The temperature may at first 
reach 104° F. (40° C.) or above, and gradually drops to the normal 
with subsidence of the symptoms. Otitis and suppuration of the 
submaxillary and retropharyngeal lymph-nodes may cause the tem- 
perature to become remittent or intermittent. 

Septic Form of Diphtheria. — In the second clinical form of diph- 
theria there are, in addition to the local symptoms present in the 
first form, constitutional symptoms of a severe or even septic type. 
The children at the outset appear very ill ; the temperature is high, 
there is marked restlessness with a tendency to drowsiness, the face 
is flushed, and the breathing noisy or nasal. The infants refuse the 
breast or bottle, and older children complain of great pain in swal- 
lowing. In some cases the glands at the angle of the jaw are 
swollen, and the neck is more rotund than normal. Inspection of 
the throat shows the membrane on the tonsils, or on both uvula and 
tonsils. It spreads rapidly, the tonsils, soft palate, and pharynx 
being covered in one or two days. The membrane may break down, 
and masses of necrotic tissue be expectorated. In severer forms the 
membrane extends over the posterior nares, and gradually invades 
the nasal passages. At first a slight nasal serous discharge is 
noticed, which increases in amount and becomes ichorous and tinged 
with blood ; the anterior nares become eroded and are coated with a 



DIPHTHERIA. 213 

whitish or greenish membrane. In some cases the membrane in- 
volves the buccal mucous membrane. There is severe stomatitis, 
the lips are eroded, and the angles of the month may show rhagades 
covered with membrane. With the development of these symptoms 
the toxaemia increases ; the fever may be moderate, not exceeding 
102° or 103° F. (38.8° or 39.4° C.) ; 'the pulse is rapid and feeble ; 
the sensorinm somewhat benumbed. The lymph-nodes at the angle 
of the jaw may be much enlarged, and the tissue underneath the jaw 
may be the seat of phlegmonous inflammation. The breath has a 
very fetid odor. The urine may reveal the presence of albumin, a 
slight amount of blood, and a few casts of the hyaline or epithelial 
type. 

The constitutional symptoms may diminish in severity, and with 
the subsidence of the local symptoms the appetite returns, the 
sensorinm brightens, and recovery gradually takes place. On the 
other hand, if a fatal issue occurs, it results from heart paralysis, 
paralysis of the general nervous system and respiratory function, or 
extension of the diphtheritic process to the larynx, trachea, and 
lungs. 

If the diphtheria extends to the larynx, the voice becomes first 
husky, then croupy. The breathing is labored and of the laryngeal 
or croupy type, there is retraction of the suprasternal notch and 
epigastrium, the accessory muscles of respiration are drawn into play, 
and unless relieved the patient dies of suffocation. Even if relieved, 
when the septic symptoms and toxaemia are severe the patient may 
succumb or the process may spread downward, and involve the 
trachea and lungs. In those cases in which there is cardiac paraly- 
sis, vomiting and abdominal pain supervene. The patient is pale 
and the surface cool. Gallop rhythm sets in and the heart-sounds 
become indistinct. The expression is at first anxious, then apa- 
thetic; the voice is scarcely audible ; the patients no longer notice 
their surroundings. Death ensues from pulmonary oedema witli 
sy m pto m s of h e; i rt -fa i 1 u re . 

If the general nervous system is involved, paralysis of the soft 
palate sets in even after the membrane has disappeared from the 
tonsils and pharynx. The reflexes are absent, and the child is 
unable to -it upright. The act of swallowing not only becomes diffi- 
cult, but fluids may find their way into the larynx and thence into 
the trachea, causing pneumonia ; or the paralysis may extend to the 
diaphragm, when the lethal issue is hastened by paralysis of the 
respiratory apparatus. 

The Malignant Septic Form. — This form has been partly described 
above. It is characterized not only by the malignancy of the local 
process, but by the severity of the toxemic symptoms as well. It 
was formerly believed that these cases were due to mixed infections 
with streptococci and staphylococci, but it is now known that the 



214 THE SPECIFIC INFECTIOUS DISEASES. 

Bacillus diphtheria^ alone may cause all the symptoms. In these 
cases not only the toxins, but the bacillus itself also enters the cir- 
culation. The pharynx, tonsils, and nares are covered with a dirty 
brown or greenish membranous exudate. There is an ichorous dis- 
charge from the nares. The tonsils, pharynx, and lymph-nodes of 
the neck become necrotic. The membrane is discharged from the 
nose and mouth. The fetor of the breath is extreme, and the pros- 
tration correspondingly great. The larynx, trachea, and lungs may 
be involved in the diphtheritic process. The pulse is weak and 
rapid. The temperature may not be above the normal, and in some 
cases may be subnormal. Acute nephritis may be present. In some 
cases hemorrhage under the skin and from the nose, mouth, bowel, 
and even kidney, may precede death. 

A few cases recover, but in them the necrosis of tissue in the 
pharynx and larynx causes permanent defects and cicatricial con- 
tractures. Loss of the uvula and perforations of the soft palate may 
result from diphtheria in early life. 

Laryngeal diphtheria (croup) is the result of the extension of a 
mild or severe tonsillar or pharyngeal diphtheria. There may be no 
preceding clinical manifestations. There are the rare cases of so- 
called ascending croup, whose existence has not been wholly dis- 
proved. Cases are seen in which the most careful inspection has 
failed to detect preceding disease of the pharynx, epiglottis, or tonsils. 
Lastly, there is a class of cases which occurs, during convalescence 
from pharyngeal or tonsillar diphtheria. 

The symptoms vary accordingly as the disease manifests itself 
first in the larynx or follows a localized tonsillar or pharyngeal diph- 
theria. In the latter case there may be slight redness of the tonsils 
or pharyngeal mucous membrane, or the parts above the larynx 
may show membranous deposits. In either case the laryngeal 
invasion is ushered in by croupy cough and stridulous or metallic 
breathing. The cough is harassing and persistent, and the stridor 
increases within twenty-four or forty-eight hours to such an extent 
as to be distinctly audible, and to give the impression that there 
is a mechanical obstruction in the larynx. The breathing becomes 
labored, and there is retraction of the parts above the sternum 
and of the peripneumonic groove, especially at the epigastrium. 
In rachitic infants the sides of the chest and the epigastrium are 
markedly retracted at each descent of the diaphragm. With increas- 
ing obstruction the face assumes an anxious expression, the lips 
become cyanosed, and the surface cool. The pulse is rapid — 120 
to 180. The fever may be high or low. The lividity of the face 
in the severer forms of dyspnoea gives place to pallor. The picture 
of laryngeal obstruction, with the stridulous breathing, increased 
respirations, and overaction of the accessory muscles of respiration, 
is so characteristic as to be significant to even the inexperienced 



DIPHTHERIA. 215 

observer. During the paroxysms of coughing membranous easts are 
expelled from the larynx. The membrane may extend downward, 
involving the trachea and bronchi, easts of which may be expelled. 
The lungs may become involved, and in severe eases are the seat of 
a bronchopneumonia of streptococcic nature. With this there may 
be compensatory emphysema. The urine may show the existence of 
slight or extensive nephritis, or may be normal in every respect. 

Especially deceptive arc those cases of membranous laryngeal 
diphtheria or croup whose onset closely resembles that of so-called 
catarrhal laryngitis. In these the symptoms may develop suddenly, 
and within twenty-four hours the patient presents all the symptoms 
of laryngeal obstruction (croup dVmblee of the French). Inspection 
may show little variation from the normal appearances in the pharynx. 
We should be cautious not to assume that no membrane is present in 
the larynx. Cases have been recorded in which laryngoscopy exam- 
ination failed to show membrane in the larynx, but in which post 
mortem it was found present beneath the cords and in the trachea. 

Course and Duration. — In the mildest and purely local forms 
the disease reaches its height in from two to four days; the tem- 
perature then drops to the normal and convalescence is established. 
In the severe septic forms the membrane spreads from the tonsils 
to the pharynx, and the disease attains its full development in from 
five to eight days. The temperature falls by lysis or crisis, and 
convalescence is established. If the case is very severe, the disease 
shows no tendency to limit itself, the toxaemia is extreme and the 
involvement of the lymph-nodes is very great. Death may ensue 
in from a week to fourteen days. In some very malignant cases 
death may ensue in from three to four days after the onset of the 
disease. The laryngeal diphtheritic croup reaches its full develop- 
ment as a rule early — within three days. The disease may then 
retrograde under treatment or may advance into the trachea and 
bronchi, and cause death in a variable length of time. 

The complications include bronchopneumonia, pleuritis, gastro- 
enteritis, retropharyngeal abscess, suppuration or necrotic destruc- 
tion of the lymph-nodes of the neck, nephritis, cardiac paralysis, 
early and late (or post-diphtheritic) general paralysis, and diphtheria 
of the eyes, skin, and vulva. 

Bronchopneumonia and Pleuritis. — Bronchopneumonia is found 
in from 50 per cent. (Baginsky) to SO per cent. (Talamon) of the 
autopsies on children who have died of diphtheria, it results 
from extension of the disease from the trachea into the smaller 
bronchi and alveoli of the lung, and is therefore always a true 
bronchopneumonia. Through the investigation- of Loffler, Flex- 
ncr. Xorthruj), and Prudden, it has been proved that the diphtheria 
bacillus, the Streptococcus pyogenes, the Staphylococcus pyogenes, 
and the pneumococcus arc the exciting causes of the pneumonia. In 



216 THE SPECIFIC INFECTIOUS DISEASES. 

the pneumonia resulting from the diphtheritic or pseudodiphtheritic 
processes complicating scarlet fever and measles, Prudden and 
Northrup have shown that the Streptococcus pyogenes is an active 
causal agent. The onset of a complicating pneumonia is generally 
indicated by an exacerbation of the dyspnoea, fever, and cough. 
The prostration is also more marked. Auscultation of the inferior 
lateral or posterior parts of the chest on one or both sides reveals 
the presence of bronchopneumonia ; while resolution is taking place 
in one part of the lung, other areas are being involved. Thus an 
apparent improvement may be followed by a rapid rise of tempera- 
ture, increased dyspnoea, and rapid pulse. This form of broncho- 
pneumonia may be complicated by pleuritis of a serous, serofibrinous, 
purulent, or hemorrhagic type. 

Gastro-enteritis. — In nurslings there is frequently a diarrhoea with 
green stools and vomiting. In some cases these symptoms may 
become severe. Extension of the membrane into the oesophagus, 
stomach, and gut may take place, with a fatal result. The cases of 
simple diarrhoea are directly due to the swallowing of bacteria from 
the mouth and fauces. The diarrhoea may be so severe as to become 
one of the leading features of the disease. 

Retropharyngeal abscess occurs in the tonsillar and pharyngeal 
forms of diphtheria as a result of infection of the retropharyngeal 
lymph-nodes by streptococci. 

Nephritis may be absent, slight, or severe. Baginsky found it 
present in 42 per cent, of his cases. In the majority of cases of even 
mild diphtheria there is albuminuria ; in some the urine may, in 
addition, contain casts, blood-cells, renal epithelium, and leucocytes, 
showing grave lesions of the kidneys. 

Heart paralysis. Of greatest clinical significance is the cardiac 
diphtheritic paralysis, which may become apparent either early 
during the course of the disease or later on in convalescence. The 
early form may set in while the membrane is still visible in the 
throat. It occurs in the septic forms of the disease. These are 
the severe cases. The children show great prostration and apathy ; 
the pulse is rapid and irregular ; the heart-sounds, especially the 
muscular sound, is indistinct ; the pulse is feeble and flickering ; 
there are vomiting and abdominal pain. These symptoms may 
repeat themselves in attacks, until finally the patient dies with all 
the symptoms of collapse, such as cool extremities and shallow 
respirations. In such cases there is, as a rule, a marked nephritis. 
In the late cases the symptoms of cardiac failure appear from the 
second week of the disease to the seventh week of the convalescence. 
The membrane has disappeared from the throat. There may be 
no premonitory symptoms, or there may have been a slight blowing 
murmur at the apex. In their mildest form the heart symptoms 
appear in the second or third week. The heart becomes irregular, 



DIPHTHERIA. 217 

and the muscular sound is weak ; the pulse becomes small and 
either slow or rapid (tachycardia). There may be attacks of syncope, 
during which the patients vomit, complain of abdominal pain, and 
refuse medicine and nourishment. Sudden cardiac failure and death 
without symptoms, premonitory or otherwise, may occur in the 
period of convalescence. 

Mild forms of cardiac irregularity which do not eventually prove 
fatal are seen in the beginning of convalescence. The severe forms 
of cardiac paralysis set in with symptoms of the early cases. These 
symptoms may have been preceded by the milder symptoms of cardiac 
irregularity. There is slight albuminuria. Suddenly, while in 
apparent good health, the patients complain of dyspnoea and pain 
in the stomach. The lips become cyanosed and the extremities 
cool, the pulse thready, the heart impulse weak, the heart-sounds 
scarcely audible ; the heart may be rapid or as slow as 40 to 50 
beats per minute. Vomiting is repeated, and in some cases the 
liver is enlarged. The patients may survive one or two such attacks, 
only to succumb finally. In the early forms of cardiac paralysis there 
may be no gross lesions in the heart-muscle. In the later forms the 
lesions are more apparent. There are fatty parenchymatous changes. 
In other cases there may in addition be changes in the vagi. 

Diphtheritic Paralyses. — Paralyses are the result of the action of 
the toxins of the Bacillus diphtheria? on the nerve-trunks and tissues 
of the general nervous system. The paralysis may occur in the 
course of the disease or during convalescence. When the paralysis 
occurs early, it affects the velum pendulum palati. In cases which 
result fatally the heart becomes affected, pneumonia caused by the 
passage of food into the larynx develops, or the paralysis may 
become general. In the latter case the symptoms are similar to 
those seen in the post-diphtheritic forms of paralysis. This form 
of paralysis manifests itself from the second to the sixth week after 
the onset of the disease. In mild forms, it may begin with a paralysis 
of the muscles of the soft palate, which remains localized. The child 
has a nasal tone of voice, and liquid food is regurgitated through the 
Dose on swallowing. In severe cases there are in addition loss of 
the patellar reflexes, ataxic conditions, inability to sit upright or to 
stand, oculomotor paralysis, facial paralysis, pallor, weak heart, 
arhythmia, loss of appetite, and albuminuria. 

Recovery may take place even when there is general involvement 
of the muscles. The great danger Is extension of the paralysis to the 
diaphragm. Post-diphtheritic paralysis occurs in 5 to 7 per cent. 
of the cases of diphtheria, according to Baginsky, who reported 131 
cases of paralysis in 2300 cases of diphtheria. The soft palate was 
most often affected. Among the other forms of paralysis are 
those of the facial and oculomotor nerve-, the larynx (recurrent 
laryngeal), and lastly forms of ataxia. Antitoxin has little effect in 



218 THE SPECIFIC INFECTIOUS DISEASES* 

preventing these paralyses. They occur as frequently after its ad- 
ministration as during the pre-antitoxin period. 

In the American Pediatric Society's tabulation 9.7 per cent, of the 
cases had paralysis ; of these, 32 out of a total of 328 cases died of 
cardiac paralysis. 

Hemiplegic cerebral palsy may occur in diphtheria (Monti, Levi, 
Baginsky). 

Disturbances of the sensory nerves also occur in diphtheria, such 
as perversions of the senses of smell and taste ; also anaesthesia of 
the rectum. 

Psychical derangements such as melancholia, have been reported. 

Diphtheritic Ophthalmia. — True diphtheritic ophthalmia occurs 
both as an accompaniment of diphtheria of the fauces and as an 
idiopathic affection. There are two distinct forms of pseudomem- 
branous affection of the eye. In the first, the Lofner bacillus is 
present, but in the second, or diphtheroid form, it is absent, and 
the streptococcus alone is found. Of the true diphtheritic form, 
one class of cases has a mild clinical course. In these the bacillus 
isolated resembles the pseudodiphtheria bacillus in. not possessing 
virulent properties. In the other form of diphtheritic eye affection 
the membrane spreads rapidly and causes destruction of the eye. 
The diphtheritic invasion is ushered in with redness and chemosis. 
The membrane appears first on the palpebral conjunctiva, and causes 
marked swelling of the lids. There is little seropurulent discharge. 
In the progressive form destruction and perforation of the cornea 
result. I have seen several cases in connection with fatal diphtheria 
complicating measles, and also cases in which there was no history 
of diphtheria in the patient or family. I have seen it occur as an 
idiopathic affection in nurslings. According to Baginsky, diphtheritic 
ophthalmia occurs in 3 per cent, of the cases of diphtheria, and is 
most frequent from the second to the sixth year. 

Diphtheria of the skin occurs when the specific bacillus finds 
lodgement in an abrasion or cut. The membrane spreads over the 
wound and encroaches on the surrounding skin. 

Diphtheria of the vulva is met with both as an idiopathic affection 
and as a complication of true diphtheria elsewhere in the body. 
I have not found the Klebs-Loffier bacillus in a number of pseudo- 
membranous inflammations of the vulva and vagina in infants. Some 
of these cases show the presence of true membrane ; others begin as 
aphthous ulceration and develop membrane later. These cases are 
benign. The diphtheritic bacillary cases may be divided into two 
distinct classes according to their causation. The cases of one class 
show the Lofner bacillus, but are benign in course, although I have 
proved by animal experiment the presence of the bacillus of diph- 
theria in virulent form. In the other class of cases there is extensive 
destruction of tissue, and sometimes a fatal result. Cases of this 



DIPHTHERIA. 219 

class occur as a complication of diphtheria elsewhere in the body or 
id connection with the exanthemata. 

The symptoms of diphtheria of the vulva and vagina may be 
localized strictly to the parts, or there may, as in the severer forms 
of Henoch, be constitutional symptoms of toxaemia. Locally, the 
disease is characterized by the appearance of patches of membrane 
on the inner surface of the labia, clitoris, and introitus vaginae. The 
parts, especially the labia majora, are intensely swollen and oedem- 
atous. In Henoch's cases there was gangrene or necrosis of neigh- 
boring tissues. In my cases there was no complicating diphtheria 
of other parts. The cases occurred in infants and in children under 
two years. They were benign in course, although of bacillary type. 

Nasal Passages. — Councilman, Mallory, and Pearce, in their latest 
monographs on diphtheria, call attention to the frequency of invasion 
of the accessory sinuses of the nose and antrum by the diphtheritic 
process. They found the antrum affected in 33 cases of 52 ex- 
amined. Clinically, this affection is more common than appears 
from these figures. This would account, according to these authors, 
for the persistence with which diphtheria bacilli continue in the nasal 
secretions after the throat lesions have disappeared. The disease of 
the antrum may, as pointed out by Wolff, and recently by Mayer, 
persist after the diphtheria has run its course. Mayer classifies the 
symptoms as eversion of the lower lid, fistulous opening in the cheek 
from which pus exudes, and a fetid purulent discharge from the nose 
on the side of the face at which the fistula is situated. 

Other Complications. — Diphtheria in pertussis is a serious compli- 
cation, since the resistance of the patient is generally much decreased. 
Bronchopneumonia is especially to be feared. In tuberculosis the 
patient usually dies as a direct result of the complication. In measles 
the diphtheritic process is a grave complication ; it may invade the 
larynx and death may ensue from extension of the disease to the lungs. 
In typhoid fever the process causes death by invasion of the lungs. 

Exanthem. — Is there an exanthem characteristic of diphtheria ? 
I am inclined to view all eruptions which may occur in the course of 
this disease as purely accidental. They may be the result of reme- 
dies (antitoxin) administered or of some infection originating in the 
gut. Among these eruptions are the various form- of erythema and 
roseola. Erythema urticatum is often seen. 

The diagnosis of diphtheria must be considered in its clinical 
and bacteriological aspects. Clinically the characteristic and ever- 
present lesion i- the membrane This is -ecu on the tonsils, uvula, 
pillars of the fauces, and the posterior pharyngeal wall. It< color 
varies. In consistency it may vary from a thin pellicle or cloudy 
discoloration t<» a thick adherent, pultaceous or stringy mass. In a 
large proportion of cases the presence of the membrane and other 
characteristics are presumptive evidence of diphtheria. On the 



220 THE SPECIFIC INFECTIOUS DISEASES. 

other baud, there are certain forms (not very frequent) of pseudo- 
membranous inflammation of the tonsils and fauces which are not 
truly diphtheritic ; these are called pseudodiphtheria or diphtheroid. 
In these cases the Klebs-Lomer bacillus is not found, but strepto- 
cocci, staphylococci, and other bacteria are present. Some forms 
of diphtheria show at first only fibrinous specks on the tonsils ; in 
others there are small necrotic ulcerations on the tonsil, and in still 
others the diphtheria may simulate an acute catarrhal follicular 
amygdalitis or lacunar amygdalitis. These cases are not as infrequent 
as was formerly supposed. In the pseudomembranous and other 
forms of inflammation of the throat above described a bacteriologi- 
cal test should always be made. It should be practised as a routine 
procedure in all cases of angina. Cultures should be made in cases 
of laryngeal inflammation in which no membrane is visible in the 
fauces. If membrane be present in the fauces, and a culture fail to 
reveal the Klebs-Lomer bacillus, a second and even a third culture 
should be made. I have frequently established the presence of the 
specific bacillus in membrane in cases in which the first culture-test 
proved negative. It is not a reliable nor satisfactory method to 
spread membrane or secretion from the throat direct on a cover- 
glass, and decide from such a preparation the nature of the process. 
The technique of culture-tests is scarcely within the scope of this 
work. It is sufficient to state that growth can be obtained within 
four or five hours if the culture-tube is subjected to a temperature of 
100.4° to 102.2° F. (38° to 39° C.) in a small incubator. Other 
diseases, such as membranous forms of stomatitis, may simulate diph- 
theria. In these cases the culture test is the only positive mode of 
making a diagnosis. Certain forms of laryngismus stridulus resem- 
ble acute diphtheritic laryngitis, or a diphtheritic process may be 
present in the larynx in a rachitic infant subject to attacks of 
laryngismus. Cultures should be made in all such cases. 

In small towns and country districts the practitioner without the 
aid afforded by laboratories will often be thrown on his own resources 
in making a diagnosis. In such cases the following clinical symptoms 
may be considered fairly presumptive evidence of diphtheria : 

The presence of membrane on a tonsil and a small patch, streak, 
or speck of membrane on the adjacent surface of the uvula or tip of 
the uvula ; a patch of membrane on the tonsil and an accompanying 
patch on the posterior pharyngeal wall ; the presence of a croupy 
cough and stridulous breathing with small patches of membrane on 
the tonsil or epiglottis, are all of much diagnostic value. The 
presence of albumin in the urine is of little value in making a diag- 
nosis, as it may be present in non-diphtheritic affections and absent 
in diphtheria. Constitutional symptoms are only of corroborative 
value. It is well known that the most virulent forms of diphtheria 
may at first be manifested by few constitutional symptoms. The 



DIPHTHERIA. 221 

temperature-curve is not characteristic. If a patient who at first suf- 
fers from a catarrhal tonsillitis of pharyngitis, shows within twenty- 
four hours minute patches of membrane either on the uvula or 
pharynx, it may reasonably be assumed that true diphtheria is pres- 
ent. An acute laryngeal inflammation, croupy cough, and stridulous 
breathing which not only persist beyond the first twenty-four hours 
or first night, but also become aggravated, justify a diagnosis of diph- 
theria of the larynx, although no membrane is visible in the throat. 
General symptoms are of little diagnostic value. Rhinitis at first ac- 
companied by a serous and later by a fetid sanguiuolent discharge, 
with glandular swellings in the neck, is diagnostic of diphtheria. 

Adenitis is frequently absent at the outset of tonsillar diphtheria, 
even when patches of membrane of some size are present. On the 
other hand, a simple catarrhal tonsillitis is often accompanied by 
marked adenitis. 

Paralysis of the soft palate, appearing in the course of a severe 
or mild pseudomembranous tonsillar, pharyngeal, or laryngeal in- 
flammation, or after the affection has run its course, points strongly 
to true diphtheria, although cases of paralysis of the soft palate 
following diphtheroid have been reported. The color of the mem- 
brane, its detachability, and the fact that a bleeding surface is left 
after its removal, cannot be relied upon as aids to diagnosis, in view 
of the fact that interference with the membrane is not advisable. 

Aphthae with pseudomembrane over the vault of the hard palate, 
spreading to the gums and cheeks, are seen in newly born and older 
infants. These forms of pseudomembranous stomatitis are the result 
of traumatism inflicted by the infected fingers of the nurse or mother, 
and are limited to the parts on which they are first seen. Such septic 
membranes rarely spread unless the exciting causes are perpetuated. 

Herpes of the pillars of the fauces, so-called herpes of the tonsils, 
lias often in my clinic been mistaken for diphtheritic patches. With 
a suitable light such an error should seldom be made. 

Following the ingestion of caustic alkali or the traumatism con- 
sequent on washing or rubbing the mucous membrane, aphthous 
ulcerations, which closely simulate diphtheritic membranous patches, 
are prone to appear over the hamular process of the palate bono. 
The history of the case, the absence of diphtheria elsewhere, and 
the result of a culture test will exclude diphtheria. 

The patches of necrotic tissue seen on the tonsils, pillars of the 
fauces, and uvula following tonsillotomy and ablation of adenoids, 
and sometimes accompanied with paralysis, may mislead the observer 
and cause him to make a diagnosis of true diphtheria. 

The membranous patches which appear on the tonsils of scarlet 
fever patients at the outset of the disease are for the most part diph- 
theroid. Unless the patient has been exposed to a double infection, 
which is infrequent in private practice, the patches of membrane 



222 THE SPECIFIC INFECTIOUS DISEASES. 

which appear later in the disease are also of a diphtheroid nature. 
True diphtheria may coexist with scarlet fever (Baginsky, Escherich, 
Councilman), but does so in only a small number of cases. 

The appearance of a pseudomembranous exudate on the tonsils of 
a patient attacked with measles should be regarded as diphtheritic until 
the contrary has been proved. The laryngitis with croupy cough and 
breathing often complicating measles is not, as a rule, diphtheritic. 

The prognosis and mortality vary with the age of the patient, 
the form and severity of the infection, and the extent to which 
organs other than the fauces and larynx are involved. Young in- 
fants, unless coming early under observation, give a high mortality 
rate. Septic forms of diphtheria are more fatal than those in which 
the process is a distinctly local affection. The mortality also varies 
with the nature of the epidemic. In Baginsky's statistics of 2711 
eases, the mortality from the sixth to the twelfth month was 52 per 
cent. ; from the second to the third year, 37 per cent., decreasing to 
8 per cent, in the tenth year. The death-rate is high in infants and 
children of delicate constitution and in those suifering from any 
form of dyscrasia. 

The treatment of diphtheria may be prophylactic, constitutional, 
and local. 

Prophylaxis. — The patient should be isolated as soon as the mem- 
branous deposit is detected. Other children of the family who have 
been in contact with the patient should at once be given immunizing 
doses of antitoxin, and the furniture of the sick-room, such as hangings 
and carpets, should be removed, only the most necessary articles being 
retained. The room should be well ventilated. The nurse should 
not come in contact with other members of the family. All ar- 
ticles of clothing worn by the patient should be dipped in an anti- 
septic solution (corrosive sublimate, 1 : 2000) before removal from 
the sick-room. The physician, before entering the sick-room, should 
cover his head with a cap and wear a long coat or bath-robe, which 
should be hung outside the sick-room. If it is necessary for mem- 
bers of the family to enter the room, they should observe the same 
precautions, and on leaving the room they should gargle or rinse 
the mouth with some mild cleansing solution, preferably of boric acid. 
A culture should at once be made. The swab should be rubbed over 
the tonsils if they are the seat of exudate ; if the case is laryngeal, 
the swab is passed over the epiglottis and posterior pharyngeal wall. 
Utensils used in feeding the patient should not be used by others. 

The patient after convalescence should not mingle with other 
children until culture has proved the absence of the Bacillus diph- 
theria? from the throat. 

Constitutional treatment consists first in the administration of 
diphtheria antitoxin. It is not within the scope of this work to 
enter into the details of the theory of action of this agent, which is 



DIPHTHERIA. 223 

the outcome of the modern experimental method of the investigation 
of disease. Its place in the therapy of diphtheria is now assured. 
The mortality of diphtheria has been greatly reduced since its intro- 
duction. Baginsky gives the following figures, showing the mortality 
before and after the introduction of antitoxin : 

Age. Before. After. 

Two years 60.2 per cent. ; 25.8 per cent. 

Two to four years 51.2 " " ; 17.1 " " 

Eight to ten years 28.8 " " ; 10 " " 

Of 5794 cases in private practice collected by the American 
Pediatric Society, the total mortality was only 12.3 per cent. In 
the cases injected on the first day of the disease the mortality was 
7.3 per cent. In the laryngeal form of diphtheria the results have 
been especially favorable. In 1704 cases operated and not operated 
there was a mortality of 21 per cent., of the intubated cases, 23 
to 27 per cent., as against 60 to 70 percent, before the introduction 
of antitoxin. 

The dosage varies with the age of the patient, the severity of 
the infection, and the duration of the case before the beginning of 
treatment. Mild forms of local membranous affections of the tonsils 
and pharynx coming under observation on the first day should receive 
doses of antitoxin as follows : Up to one year, 600 units ; one 
to two years, 1000 units ; two to five years, 1500-2000 units. 
If the disease has markedly progressed twenty-four hours after 
the first injection, the initial dose should be repeated. The severer 
forms of localized diphtheria with marked constitutional symptoms 
should receive initial doses half as large again or twice as large. 
Laryngeal forms should receive proportionately large doses. The 
American Pediatric Society recommends as an initial dose 1500 units 
for a child under two years, and 2000 units for one above that age. 
I employ 300 units for immunizing purposes in very young infants, 
and 500 units in older children. 

The immunizing power extends over a period of three weeks. It 
is best to give an initial dose of sufficient amount, so that a repeti- 
tion of the dose will not be necessary; on the other hand, it is 
advisable not to give an excessively large dose. The concentrated 
antitoxins are preferable both on account of the diminished bulk 
and the infrequeney with which skin and joint-affections follow their 
injection. Recently prepared antitoxin should be obtained, for it has 
been shown that this agent deteriorates with age (Abbott), and then 
no longer contains the original unit values. 

TlME OF INJECTION. — The antitoxin should be given as early in 
the coarse of the disease as possible. If membrane is present, no 
time should be lost in waiting for the result of the culture test, for if 
the disease is not true bacillary diphtheria no harm can result from 
the injection, while to wait may be hazardous to the patient. 



224 



THE SPECIFIC INFECTIOUS DISEASES. 



Mode of Injection. — The syringe with asbestos packing should 
be used for making injections. Such an instrument is easily cleansed 
and boiled. I find the back just above the buttock the most con- 
venient location in which to inject. The child can be easily held if 
this site is chosen. The parts should be carefully cleansed. The 
injection is given in the same manner as a hypodermic injection. The 
parts should not be rubbed after the injection, and the puncture 
should be covered with a small square of iodoform gauze. 

Effect of Injection. — There is a slight temporary rise of tem- 
perature following the injection. It is thought to be due to the 
entrance into the blood of the additional toxin contained in the. 
antitoxin. This rise is succeeded by a gradual or critical fall, which 
continues until the temperature is subnormal. The membrane ceases 

Fig. 53. 




Antitoxin syringe with asbestos packing ; can be taken apart and sterilized. 



to spread and exfoliates. In some cases these phenomena may be 
delayed twenty-four hours. The next day the pulse drops, the pros- 
tration gives way to a clear sensorium and good heart action, and 
sometimes the children sit up in bed and play with toys. The glan- 
dular swelling also diminishes markedly. In laryngeal cases if there 
has been threatened stenosis, the symptoms retrograde. Of 258 cases 
of this kind, Baginsky saw fully one-half retrograde spontaneously. 
On the other hand, if the temperature persists high after twenty-four 
hours and the membrane continues to spread, the injection should be 
repeated, especially if the swelling of the lymph-nodes is marked and 
there are symptoms of septic infection. 

The eifect of an injection of antitoxin on the blood is to diminish 
the number of leucocytes ; just prior to the fall of temperature there 
is a critical hyperleucocytosis (Ewing, Schlessinger). Albuminuria 
continues, but this is also the case not only when no antitoxin has 
been used, but also in almost any infectious disease in which bacteria 
or their toxins circulate in the blood. 



DIPHTHERIA. 



225 



The eruptions which occur after the injection of antitoxin are of 
interest. At the site of the injection an abscess or phlegmon may 
form. This is the result of imcleanliness in technique or is due to 
some irritating substance in the antitoxin. A brawny erythema 
which gradually disappears may appear in a day or more at the site 
of injection. The injection may be rapidly followed by a painful 
eruption on the extremities, consisting of circumscribed violet colored 
spots, closely resembling erythema nodosum. The subcutaneous 
tissues are swollen, the joints are painful, and in addition there may 
be elevated temperature and a cardiac murmur. Herpes labialis 
and herpes nasal is, urticaria-like general eruptions, and morbilliform 















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Septic form of tonsillar diphtheria : hoth tonsils and soft palate involved with naso- 
pharynx. Persistence of temperature and recurrence of membrane after antitoxin injec- 
tions on the sixth day. Injection of additional antitoxin, and critical drop of temperature 
thereafter. Recovery. Boy, six years of age. 

or scarlatiniform eruptions have followed injections. These eruptions 
appear from a few days to fourteen days after the injection. 

Conjunctival injection, tachycardia, and arhythmia may be 
present. 

The acute symptoms described above subside in most cases within 
two or three days. 

Kidney irritation may follow the injection of large doses of anti- 
toxin. In many of the case- reported, however, the renal symptoms 
have not been due to the antitoxin alone, and the same may be said 
of the recorded cases of endocarditis following antitoxin injections. 

The introduction of antitoxin has by no means lessened the 

15 



226 THE SPECIFIC INFECTIOUS DISEASES. 

necessity of careful general management of a case by the physi- 
cian. The temperature is controlled or modified by the ordinary 
hvdrotherapeutic procedures. Antipyretics of the coal-tar series 
should not be administered, as they weaken the heart. 

If signs of cardiac paralysis of the early type set in, full doses of 
the cardiac remedies — digitalis (if the pulse is rapid), strychnine, 
camphor, musk, and especially whiskey — are given. In order to 
guard against cardiac weakness in the later period of the disease, 
a cardiac stimulant, such as strychnine, is given in small doses 
throughout the illness and in convalescence. The patient is not 
allowed to sit up too early should signs of cardiac irregularity appear 
at the outset of convalescence. In all cases of diphtheria the utmost 
caution should be exercised in reference to the heart. 

The infant should not be nursed at the breast, lest the breast be 
infected. The milk should be pumped off and fed to the infant with 
a bottle. If there is diarrhoea, the milk is suspended and the bowel 
irrigated. The milk should not be resumed until all danger from this 
source is past. I administer alcohol in moderate doses if the pros- 
tration, pulse, and temperature warrant it. Infants under a year 
should be given half a drachm (2.0) of whiskey every three hours ; 
infants more than two years of age, a drachm (4.0) at the same inter- 
vals. Diphtheria patients, especially those suffering from the septic 
form with constitutional symptoms, should be kept recumbent. The 
administration of remedies should not be forced, for struggling on the 
part of the patient may prove dangerous to the heart. During con- 
valescence the whiskey may be replaced by wine. In these cases 
strychnine in small doses (grain -^jf [0.0003]) should be continued 
for some time, in order to support the heart. I advise a return to a 
mixed nutritious diet in all cases as soon as the temperature is nor- 
mal ; in this way the effect of the toxins on the tissues is counter- 
acted as much as possible. 

Some physicians still resort to the internal administration of 
corrosive sublimate in doses of grain y^- (0.00Q6) or more, accord- 
ing to the age of the patient. It is given in the septic tonsillar and 
nasal cases, and also in the laryngeal forms of diphtheria. 

Local Treatment. — The presence of bacteria other than the diph- 
theria bacillus around the local lesions necessitates the use of local 
cleansing and disinfecting measures. In very young infants the 
nasal discharges are washed away by means of a glass syringe with 
a blunt rubber tip. The infant is laid on the side, and the nurse, 
standing behind the patient, irrigates the nostrils with normal salt 
solution at 110° F. (43.3° C), as shown in Fig. 7. A pus basin 
is held underneath the chin. Older children will struggle, but by 
suasion they may be irrigated in the sitting posture. If there is much 
resistance, it is not desirable to insist on irrigation. In irrigating, 
the syringe should have a position parallel with the floor of the 



DIPHTHERIA. 227 

nasal fossae. Spraying with a mild solution of listerine or Dobell's 
solution is possible in some children, impracticable in others. The 
lymph-nodes, if slightly enlarged, are best treated by the application 
of warm oil of hyoscyamus ; if very much swollen, the application 
of cloths wrung out in ice-cold water .is of great utility. Small 
pieces of ice swallowed whole are grateful to the patient. 

Treatment of Laryngeal Diphtheria. — In cases of mild laryngeal 
diphtheria an injection of antitoxin should be given. The patient 
should be placed under a tent, and grains x (0.0) of calomel sublimed 
every two or three hours, according to the necessities of the case. 
The efficacy of the calomel vapor is increased by passing steam into 
the tent at the same time. A convenient method is to place the 
calomel in a spoon, and heat the spoon over an ordinary candle, 
placed within the tent. The swelliug of the larynx caused by the 
invasion of the Bacillus diphtherias and other bacteria is quickly 
relieved by the calomel, particularly in croupy cases with little or 
no membrane visible above the larynx. A tent may be improvised 
as described on page 38. Steam saturated with benzoin or thymol 
may also be passed into the tent. A croup kettle may be improvised 
from an ordinary teapot or one sold for the purpose may be em- 
ployed. It is sometimes necessary to suspend the steam inhalations* 
for an hour or longer, for the purposes of ventilation. The general 
treatment as to the heart, temperature, and food is the same as in 
the tonsillar forms of diphtheria. If signs of mechanical obstruction 
appear, intubation is indicated. 

Intubation. — To Joseph O'Dwyer, of New York, belongs the 
credit of having perfected a method of relieving membranous ob- 
struction of the larynx in diphtheria. Intubation in America and 
on the continent of Europe has completely displaced tracheotomy as 
a remedy for relieving laryngeal obstruction due to diphtheria. 

Instruments. — Intubation tubes (Fig. 55) are of metal coated with 
rubber, though originally made of gilt metal. The tubes are grad- 
uated (Fig. 56) according to the 
age of the patient, and in their Fig. 56. 

present form are the most inge- 
niously devised instruments ever 




ffiven bv American medicine to Gauge tor the age of the 

i i i rr\i i r> patient. 

the world. I he tubes are fur- 
nished with obturators, which fit into a handle, the m- 
O'Dwycr tube, troducer (Fig. 57). There is, in addition, a forceps 
(Fig. 58) with small departing blades, called the ex- 
tractor. Finally, there is a gag (Fig. 59) so constructed that it 
may be introduced into the mouth and kept in position without 
obstructing the view of the operator. 

Indications. — We intubate when a progressive dyspnoea, which 



228 



THE SPECIFIC INFECTIOUS DISEASES. 
Fig. 57. 




O'Dwyer tube, obturator, and handle. 
Fig. 58. 




The O'Dwyer extractor. 
Fig. 59. 




Gag of the O'Dwyer set. 



DIPHTHERIA. 
Fig. 60. 



229 




Introduction of the tube along the index finger. 







Fig. 


61. 








ftO 


F 




v -—- 






d 







Passing the tube over the epiglottis. 

GO, 61.— The operation of intubation of the larynx. Position of child, operator, and 

assistant. 



230 THE SPECIFIC INFECTIOUS DISEASES. 

Fig. 62. 



■ 




MRS J**"" 


,::. 


C4 • v v 








%^ 




; ^» • -s— 


■ 


. 





Introduction of the tube into the chink of the glottis. 
Fig. 63. 




The index finger pushes the head of the tube into place in the larynx. 

Figs. 62, 63.— The operation of intubation of the larynx. Position of child, operator, and 

assistant. 

produces sensible exhaustion, exists. O'Dwyer never tubed the 
larynx except as a dernier ressort, and did not approve of early 
tubage. If an infant or child shows marked retraction of the supra- 



DIPHTHERIA. 



231 



sternal notch, retraction of the epigastrium, and stridor, with accom- 
panying labored breathing, we should at once proceed to tube the 
larynx. 

Mode of Operating. — The patient is wrapped in a blanket and 
held upright in the arms of a nurse, so that the head of the patient 
is on a level convenient to the operator, who stands facing the 
patient. An assistant standing behind the nurse steadies the head 
of the patient. The gag is introduced by depressing the tongue and 
jaw with a tongue-depressor. The assistant steadies the gag as he 
holds the head tilted very slightly backward. The tube, threaded 
with a silk ligature, is with its introducer held firmly with the right 
hand. The index finger of the left hand is now introduced into the 
mouth to the root of the tongue and search made for the epiglottis. 
In young infants 1 the epiglottis is short. The finger must be intro- 
duced quite deeply, feeling the arytenoid cartilages of the larynx, 
and is then drawn upward until the epiglottis is hooked forward. 
The index finger now holds the epiglottis (Fig. 64), and in a small 

Fig. 64. 




Method of hooking forward the epiglottis in intubation. 

larynx a skilled operator can also feel the arytenoids (Fig. 65). The 
tube is now introduced in the median line of the mouth along the 



1 Peculiarities of the Larynx. — Thomson and Turner have shown that the infantile 
form of larynx differs materially from that found later in life. At birth and in infants 
and young children the epiglottis is very small and gutter shaped. The glottis 
is guarded above by the aryteno-epiglottic folds, which are closely approximated 
to each other. Toward th<- tenth year the epiglottis becomes much flattened, the 
arvteno-epigloitic folds become widelv separated, and the larynx assumes the adult 
type. It is important to remember these points in the operation of intubation. 



232 



THE SPECIFIC INFECTIOUS DISEASES. 



palmar surface of the index finger (Fig. 60), and the finger guides 
the tube over the epiglottis and into the chink of the glottis and 
prevents its slipping into the oesophagus (Fig. 61). The instru- 
ment should always be kept in the median line. The index 
finger holding the epiglottis should be held well to the angle of 
the mouth, so as to obtain plenty of room. No force should be 
used, else false passages will be made. If the first attempt at 
introduction does not succeed, we should not persist too long, but 
remove the introducer rapidly and give the larynx a few moments 
to recover its action, and then try again. As the tube passes into 
the chink of the glottis the handle of the introducer is elevated, as in 
Fig. 62, causing the end of the instrument to lie against the base of 
the tongue. The tube is released, the introducer and obturator with- 
drawn, and the index finger gently presses the head (Fig. 63) of the 
tube into the larynx. The gag is withdrawn, and the silken thread 
passed over the ear of the patient and fixed back of the ear with a 
piece of rubber plaster. Some operators remove the thread after ten 
minutes. The advantages of leaving the thread are that, should the 
tube be coughed up in the absence of the physician, it can be recov- 
ered by the nurse. In extubating, it is an aid in removing the tube. 
No anaesthetic is required, and ordinary assistance only is neces- 
sary. The air passing into the bronchi is moistened in its passage 
through the natural passages. The danger that food particles may 
pass into the larynx has been exaggerated. The detachment of mem- 
brane in front of the tube is very infrequent. Should it happen, 
and the membrane not be expelled on removal of the tube, tracheotomy 
is admissible if asphyxia is imminent. It sometimes happens that 
the tube is expelled many times after introduction. It should be 
reintroduced or a larger tube employed. 

Fig. 65. 
12 3 







The infantile larynx. Its development into the adult type at the age of nine years. 1. 
Infant, three months of age. 2. Child, three and a half years of age. 3. Boy, nine years of 
age. Enlargement upward of the epiglottis and shaping of the arytenoid cartilages. 
(Thomson and Turner, British Medical Journal, December 1, 1900.) 



DIPHTHERIA. 233 

If the operator has chosen to leave the silken cord of the tube in situ, it 
should be passed through the space between the first molar and bicuspid tooth, 
to avoid its being gradually bitten through. Should it be bitten through, the 
finger is introduced into the mouth to the top of the tube and the thread with- 
drawn, while the tube is kept in the larynx with the finger. 

The tube is allowed to remain from twenty-four hours to five 
days. Since the introduction of antitoxin the tube is taken out 
much sooner than was formerly the practice. If there is marked 
improvement in two or three days, removal of the tube should be 
attempted and the eifect of such a procedure on the breathing 
should be observed. 

Extubation. — The patient is placed in the same position as for 
intubation. The left index finger is passed into the mouth and 
search made for the epiglottis, the tip of the finger resting on the 
arytenoids. The extractor is passed along the palmar side of the 
finger and is guided into the opening in the tube by the tip of the 
finger. Extubation is more difficult than intubation. The ex- 
tractor should be regulated by means of a small screw, so that the 
blades do not open too far. This is to guard against injury to 
the soft parts of the larynx should the opening of the tube not be 
entered. 

Dangers. — The dangers of intubation include detachment of 
membrane during introduction, laceration of the parts, the forma- 
tion of false passages, and asphyxia. The first rarely occurs unless 
force is used. The second can only occur as a result of rough and 
unskilled efforts at intubation. The third occurs only following 
prolonged efforts at introduction of the tube. Even a skilful oper- 
ator may pass the tube into the ventricle of the larynx. Northrup has 
published a case in which there was a false pocket above the cords 
which prevented the entrance of the tube into the larynx. In other 
cases there is what is described bv O'Dwver as subglottic stenosis. 
Northrup thinks that this is due to swelling of the mucous membrane 
at the level of the cricoid cartilage. In these cases introduction of 
the tube is very difficult. The operator may be compelled to use 
force to push the tube past the stenosis or a smaller tube may be 
employed. While the tube is being worn, it may become obstructed 
by membrane. This is denoted by a return of the croupv cough, a 
snarling, flapping sound, and obstruction to expiration. To obviate 
these difficulties, O'Dwver lias had short tubes constructed without 
a retaining flange. These tubes have a special introducer. The 
largest size for the age is chosen, and the tube forced into the 
larynx. These tubes should be used only by skilled operators. The 
tubes are allowed to remain but a short time in the larynx. Other 
complications are the formation of granulations or ulcerations around 
the lower end of the tube if it is too long, and at the cricoid cartilage 
if it is too large. The former condition is not serious ; the latter may 



234 



THE SPECIFIC INFECTIOUS DISEASES. 



Fig. 66. 




n i 

Built-up tubes. 



destroy the cartilage. Granulations may form about the head of the 
tube. In this case tubes with built-up heads are used to press on the 
granulations, thus causing them to atrophy (Fig. 66). 

Feeding the patient after introduction of the tube requires care. 
Most infants will nurse with the tube in the larynx. In some there 
is considerable difficulty in swallowing. The 
patient is taken in the lap of the nurse and fed 
with the head held a little lower than the body. 
Fluids thus cannot enter the trachea and cause 
pneumonia. This method of feeding was sug- 
gested by Casselberry, of Chicago. 

Treatment of the Complications. — The treat- 
ment of the broncho-pneumonia which com- 
plicates diphtheria is similar to that employed 
in the treatment of the primary affection. The 
question of the further administration of anti- 
toxin always arises in these cases. I give 
it in full doses, since it is known that 
the Bacillus diphtherise is the causative fac- 
tor. 

The gastro-enteritis which complicates 
diphtheria is apt to prove a very serious com- 
plication. It should receive the same treatment 
as a primary gastro-enteritis. 

Both the severe and the mild cases of vulvovaginitis should be 
treated with antitoxin. In some of the mild forms of undoubted 
bacillary origin which I have seen, the membrane was easily remov- 
able. In these cases, contrary to the practice in the tonsillar cases, 
I remove the membrane with a spud wrapped with cotton. The 
bleeding surface left after removal is painted with a 10 per cent, 
solution of silver nitrate once daily. I have cured cases by this 
method alone. If there are extensive swelling, necrosis, and gan- 
grene, this method will be of no avail, and antitoxin should be 
given in full doses, and repeated according to indications. 

Paralyses. — The treatment of diphtheritic and especially post- 
diphtheritic paralyses is at present largely empirical. The symptoms 
appear with the degenerations in full progress. Of all the remedies 
recommended, Fowler's solution in tonic doses has seemed to give 
the best results. I have seen patients recover when given arsenic, 
nutritious food, and abundant fresh air. Hypodermic injections 
of strychnine are of questionable value. Electricity is of value 
as an adjuvant to massage of the muscles only in general paralysis. 
It is questionable whether in some cases it is not capable of doing 
great harm by tiring nerve and muscle. I find that patients do very 
well with hydrotherapy and manual massage. In these cases the last 
reaction to reappear is the patellar reflex. 



DIPHTHEROID. 235 

Diphtheroid. 

(Pseudodipktheria ; False Diphtheria.) 

The term diphtheroid includes all pseudomembranous formations 
not caused by the Klebs-Loffler bacillus. It was first proposed in 
1860 by Boussage, and has recently been adopted by Weigert, Esch- 
erich, Heubner, and Beliring. 

Occurrence. — This form of pseudomembranous formation is 
most frequently met with in the exanthemata, especially scarlet fever 
and measles. In the former it is a common complication. It is 
also met in other conditions, and may occur as a primary affection. 

Etiology. — The cases met in the exanthemata were first de- 
scribed by Prudden, who believed that the process was due to a 
streptococcus, the Streptococcus diphtherias. Since then, the occur- 
rence of the streptococci has been confirmed, but there have also 
been added to this group of pseudomembranous inflammations cases 
in which the pseudomembrane is caused by a diplococcus, the so- 
called Roux coccus. The pneumococcus (Jaccoud and Menetrier) 
may also cause a pseudomembranous angina. The Bacterium coli 
and the gonococcus (the latter in newly born infants) may cause a 
membranous formation in the mouth and throat. The Staphylo- 
coccus pyogenes aureus is also found in these diphtheroid mem- 
branes. By far the most important group is that first mentioned, 
the pseudomembranous or diphtheroid inflammation caused by the 
Streptococcus pyogenes, which is none other than that isolated by 
Prudden. These cases are characterized by their favorable course ; 
while the mortality in diphtheria varies from 20 to 35 per cent., 
according to the age of the patient, the virulence of the epidemic, 
and the early administration of antitoxin, the mortality of the 
diphtheroid cases ranges from 3 to 5 per cent. (Park, Baginsky). 

Symptoms and Course. — The pseudomembrane occurs on the 
tonsils, pharynx, and larynx. There are adenopathy and fever. 
The prostration and constitutional disturbance are much less than 
in true diphtheria. Membranes and easts of the larynx and trachea 
may be expelled. Suppuration of the lymph-nodes may also occur. 
In many of these cases there is a complicating bronchopneumonia 
of the streptococcus type (Prudden and Northrup), which usually 
results fatally. 

Diagnosis. — It is not possible to make a diagnosis of diphthe- 
roid from the gross appearance of the membrane. The culture-test 
is the only reliable method of determining the nature of a pseudo- 
membranous exudate. If the first culture gives a negative result, a 
second one should be made. 

Treatment. — Clinically the treatment is much the same as in 
true diphtheria. The administration of antitoxin should not be 
delaved until the nature of the exudate is determined. It is then 



236 THE SPECIFIC INFECTIOUS DISEASES. 

discontinued. An exception to this rule may be made in the scar- 
latinal form of diphtheroid, in which it is safe to wait for the result 
of the culture-test, unless it is known that the patient has been ex- 
posed to diphtheritic infection. In such a case antitoxin should be 
administered. In laryngeal obstruction the indications for treatment 
are the same as in true diphtheria. 

SCROFULA or SCROFULOSIS. 

Scrofulosis is a constitutional dyscrasia which occurs chiefly in 
childhood, and is characterized by enlargement of the lymph-nodes 
and slow, sluggish inflammation of the mucous membranes, skin, 
joints, and bones. There is a distinct tendency to repeated inflam- 
mations from very trivial causes. 

Occurrence. — Scrofulosis is almost exclusively a disease of child- 
hood and youth, and is rarely seen after the twentieth year. Henoch 
and Birch-Hirschfeld state that the majority of cases occur between 
the third and the fifteenth year. Females are more frequently affected 
than males. Ruhl found it to be most common between the sixth 
and the tenth year. 

Forms. — Cornet and Ponfick recognize three forms of scrofulosis : 

a. The tuberculous form, which is practically identical with 
cutaneous, lymphatic, and bone tuberculosis. 

b. The pyogenic form, in which the tubercle bacillus is absent 
in the lesions or products of inflammation, but which in its outward 
clinical manifestations closely resembles the tuberculous form. In 
this form the essential etiological factors are the Staphylococcus 
pyogenes aureus and albus and the Streptococcus pyogenes. 

c. The mixed form, in which both the tubercle bacillus and the 
pyogenic bacteria are found in the lesions and products of inflam- 
mation. 

Etiology. — In considering the etiology of scrofulosis, it shoukl 
be borne in mind that at the period of life during which the disease 
occurs the lymph-nodes are not structurally fully developed. On 
account of this condition and of deficiencies of other tissues such 
as the skin and mucous membranes, bacteria obtain easy access 
through the skin, mucous membranes, and lymph -vessels even when 
there is no breach of continuity of surface (Cornet). 

It is also true that certain individuals, once infected, show an in- 
herited predisposition to affections of the mucous membranes and 
other tissues. This does not mean that scrofulosis as such is hered- 
itary, but that in these subjects exposure to the essential causes of 
the disease will result in permanently establishing the' conditions. 

The essential causes of scrofulosis are the tubercle bacillus and the 
pyogenic bacteria just mentioned. These bacteria are present in ill- 
ventilated rooms occupied by phthisical patients. Scrofulous infection 



SCROFULA OR SCROFULOSIS. 237 

may be traced to parents, brothers, sisters, nurses, and playmates. 
Dried sputum is a prolific source of infection. Infection is favored 
by any solution of continuity of the skin or mucous membranes, and 
also by hyperemia or oedema of these tissues. 

The predisposing factors are social conditions, unhygienic sur- 
roundings, moist dark dwellings, uneleanliness, improper or insuffi- 
cient food, and lack of fresh air and exercise. The overcrowding in the 
poorer quarters of cities affords abundant opportunities for infection. 
Any weakening of the system by infectious diseases, such as measles, 
pertussis, scarlet fever, diphtheria, rachitis, struma, cretinism, and 
erysipelas, may be the starting-point for infection. Traumatism or 
frostbite favors the entrance of bacteria. 

Morbid Anatomy. — The gross pathological changes are the same 
in both the pyogenic and tuberculous forms of scrofulosis. 

The Pyogenic Form. — The mucous membranes are the seat of 
hyperemia and thickening. There are increased secretion and 
activity of the glands, also desquamation of epithelium, and excretion 
of serum and blood-elements from the surface of the membrane. 
Adenoids, enlarged tonsils, bronchitis, intestinal and vaginal catarrh, 
are the most common of the lesions of the mucous membrane. 

Skix. — There are eczema, thickening of the epidermis, and tran- 
sudation of serum and elements of the blood (erythrocytes and 
leucocytes). 

The CORNEA shows conjunctivitis and phlyctenular. 
The lymph-nodes show hyperplasia, which is scarcely noticeable 
in the early stages. They subsequently enlarge to form tumor 
masses, which may soften as a result of suppuration or may retro- 
grade to the normal. 

The Tuberculous Form. — Skin. — Lupus is the form of change 
found in the skin. 

Lymph-nodes. — The nodes in almost any part of the body may 
be involved. They are enlarged to a greater or less degree, and are 
infiltrated with tubercle. On section they show either simple case- 
ation or mixed infection. The latter is the case if pyogenic infection 
is combined with the tuberculous form. Nodes which are the seat 
of cheesy degeneration may soften and break down, forming cold 
abscesses. These may open externally or into the bronchi, blood- 
vessels, pericardium, or peritoneum. 

Joints and Bones. — In the bones the tuberculous invasion 
gives rise to fungus or dry caries. Several such foci may be present 
in the same bone. These foci may heal and years afterward become 
inflamed as a result of traumatism or infectious disease. 

The fingers, toes, and extremities of the long bones are thickened 
as the result of periosteal inflammation. The ends of the bones arc 
the seat of tuberculous osteomyelitis. The joints may be involved. 
At first there is serous exudate without perforation into the joint 



238 THE SPECIFIC INFECTIOUS DISEASES. 

of the tuberculous foci. Later there are thickening of the synovial 
membranes and seropurulent exudate into the joint-cavity, with 
destruction of the cartilages and heads of the bones. 

Symptoms. — General Clinical Picture. — The patient is anaemic, 
but not necessarily emaciated ; on the contrary, there is a very good 
panuiculus of fat in the majority of cases. The face of some of these 
subjects presents an eczematous or lupoid eruption. The lips are 
thick ; the conjunctivae may be injected, and there may be blepharitis 
or phlyctenula of the cornea. Snuffles and nasul catarrh or ozaena 
are present. The majority of the patients are mouth-breathers, 
and suffer from adenoids and enlarged tonsils. In some there is 
chronic otitis with an offensive discharge. There is a fulness about 
the neck due to enlarged lymph-nodes. The body may present skin 
eruptions in the form of ecthyma or varieties of eczema. The gen- 
eral surface is in other cases free from eruption, is pale, and has a 
transparent, marble-like appearance, showing the blue veins under- 
neath. Many of these patients give a history of chronic bronchitis. 
In others the remains of old suppurations of the lymph-nodes about 
the neck are seen in the form of livid cicatrices. If the long bones 
of the extremities have been affected, the surface of the skin shows 
either old or recent bone sinuses. The symptoms in most cases 
develop first on the skin and mucous membranes ; the lymph-nodes 
then enlarge, the bones and joints are next involved, and finally, if 
the case does not progress favorably, amyloid degeneration of the 
different organs and emaciation develop as a result of prolonged sup- 
puration. In all cases the changes in the lymph-nodes play a leading 
part, and are characteristic. 

The Skin. — In the tuberculous variety lupus is the most com- 
mon form of skin lesion ; in another form there is the so-called 
scrofuloderma of Besnier. Lichen scrofulosorum, with the character- 
istic enlargement of the lymph-nodes, is another form of skin erup- 
tion. In the pyogenic variety eczematous and acneform eruptions 
are present. In such cases the skin is thickened as a result of 
chronic inflammations. There are suppurating rhagades around the 
eyes, mouth, and anus, and ecthymatous eruptions may be present 
on the trunk and extremities. A form of scrofulous ecthyma, made 
up of purple painful nodules resembling erythema nodosum, has 
been described by Hutchinson. Hebra has described a prurigo of 
the scrofulous subject. 

Mucous Membranes. — There are ulcerations and chronic catarrh 
of the nasal and bronchial mucous membranes, and in some cases 
ozaena of an atrophic character. These patients have adenoids and 
enlarged tonsils. The tonsils are favorit' seats of infection. In 
other cases the posterior nasal and pharyngeal catarrh leads to retro- 
pharyngeal abscess, or caries of the spine may cause abscess forma- 
tions in the retropharynx. 



SCROFULA OR SCROFULOSIS. 239 

The Ears. — As a result of the catarrh of the nasopharynx 

chronic otitis may develop. When otitis follows any of the exan- 
themata in a patient with scrofulous tendencies, it pursues a chronic 
painless course. Such an otitis may tend to tuberculous disease of 
the mastoid with sinus thrombosis, or even to tuberculous meningitis. 
There is pain only when there is a mixed pyogenic infection. 

The Eye. — Chronic eczema of the lids, blepharitis, phlyctenula 
of the cornea, and keratitis fasciculosa are seen. The phlyctenule do 
not yield readily to treatment. Hypopyon of the anterior chamber 
may also be present. Trachoma is in some instances of a tubercu- 
lous origin. Lupus of the conjunctiva is sometimes present. 

Lymph-xodes. — The tuberculous and pyogenic forms of enlarge- 
ment of the lymph-nodes are at the outset similar. The pyogenic 
varieties are associated with enlarged tonsils and adenoids. The 
skin over the enlarged nodes may remain normal for months or 
years, or in both the tuberculous and pyogenic varieties it may 
become adherent, red, inflamed, and break down. The lymph-nodes 
discharge, leaving suppurating cicatricial openings. 

Clinically, infections of the scalp lead to enlargement of the 
lymph-nodes of the neck and retromaxillary region. Those of the 
cornea, iris, and ear tend to enlarged preauricular nodes and to en- 
larged nodes of the submaxillary region. Infections of the mouth 
and tonsil cause enlarged nodes at the angle of the jaw and beneath 
it. Otitis with mastoid disease causes enlargement of the node on 
the point of the mastoid. The lymphatics of the gums and lips are 
connected with the nodes of the submaxillary region and angle of the 
jaw. Affections of the nose will cause enlargement of the glands 
of the neck (Jacobi). Lesions of the fingers will result in enlarge- 
ment of the cubital and axillary nodes. Infection of a circum- 
cision wound or balanitis will cause enlargement of the inguinal 
lymph-nodes, as will also infections of the foot and knee. 

The lymph-nodes in direct line are always involved ; distant ones 
are never infected unless there is infection of the intermediate nodes. 
It was formerly believed that the bronchial nodes were particularly 
subject to infection. Any special susceptibility to infection shown 
by these nodes is due to their location, infectious material being fre- 
quently present in their vicinity. 

Cornet found the bronchial nodes affected in 103 out of 126 
cases of tuberculous disease occurring before the completion of the 
fifteenth year. These observations confirm the statement of Henoch, 
that the bronchial nodes are affected in the majority of cases of 
tuberculous disease. There are no statistics showing the involve- 
ment of lymph-nodes in the pyogenic forms of scrofulous. Becker, 
Barthez and Rilliet, Henoch, and Northrup have described the 
enlargement of bronchial node-. According to Henoch, they may, 
even if tuberculous, be enlarged without involving the lung tissue. 



240 THE SPECIFIC INFECTIOUS DISEASES. 

By pressing on the vagi they may cause rapidity of pulse, and if 
on the recurrent laryngeal may give rise to spasmodic dyspnoea or 
to a croupy cough. Pressure on the oesophagus may cause dysphagia ; 
pressure on the trachea may cause inspiratory dyspnoea ; and pressure 
on the pulmonary veins, hyperemia of the lungs. Henoch and 
Baginsky doubt the possibility of diagnosing these enlarged nodes 
even with the .help of all these symptoms. 

These nodes may retrograde to the normal size (West) or they 
may break down and perforate into a bronchus or the trachea. If 
they perforate into the pericardium, pleura, or mediastinum, inflam- 
mation results at these points. 

The mesenteric lymph-nodes may enlarge and cause pain or 
tuberculous infection of the peritoneum (tabes meseraica). In some 
cases they may be palpated through the abdominal wall. 

The Bones and Joints. — The extremities of the long bones are 
most frequently the seat of disease ; the diaphysis rarely so. The 
phalanges of the fingers, the toes, the radius, the ulna, and fibula, 
are affected in the order of naming. The joint-cavities may at first 
contain exudate without perforation of the cartilage ; later, pus is 
found in the cavity. 

All of the structures of the joint are involved, and the joint 
may eventually be destroyed. Suppuration of a chronic nature may, 
as stated elsewhere, tend to amyloid degeneration of the liver and 
spleen. 

There is, in addition, a progressive anaemia. The temperature 
is sometimes raised a half or three-quarters of a degree above the 
normal, at others it is normal. Exhausting sweats occur ; the dis- 
turbances of nutrition become in some cases extreme. There may be 
intestinal diarrhoea. 

Course and Prognosis. — This condition is not necessarily fatal. 
Many cases make a good recovery under proper management. This 
is particularly true of the pyogenic form. The tuberculous variety 
may also retrograde if the disease be localized to certain lymph- 
nodes or bone foci. 

Diagnosis. — The diagnosis of the pyogenic form is made from 
the clinical history ; that of the tuberculous variety, either from the 
presence of the tubercle bacillus in the pus or lesions of the disease. 
There are mixed forms in which it is not always possible to decide 
whether the process is tuberculous or pyogenic. The clinical history 
and blood examination will be of service in differentiating scrofu- 
losis from leukaemia, pseudoleuksemia, and lymphomata of a malig- 
nant nature (Plate XII.). In other cases the diagnosis from 
late forms of hereditary syphilis cannot always be readily made. 
The history of such cases is of importance. In many cases a 
resort to antisyphilitic treatment will be necessary to complete 
the diagnosis. 



PLATE XII 




Multiple Lymphosarcomata as Differentiated from Scrofulous 
Lymphadenitis. Enlargement of the cervical, supraclavicular 
and axillary lymph-nodes. Child six years of age. 



TUBERCULOSIS. 241 

The treatment of scrofulosis is directed toward limiting if 
possible the spread of the infection, preventing reinfection of the 
patient, and instituting local treatment of the lesion. In order that 
the disease may be treated successfully, the patient should be placed 
under hygienic surroundings. If the patient is in the city, removal 
to the country is advisable. The food should be plain and nutritious ; 
milk, eggs, meat, vegetables, and cereals should form the diet. The 
hygiene of the skin is important. Alkaline or sea baths give tone to 
the skin. Moderate exercise in the open air is also of great service 
in correcting the anaemia and tendency to inaction shown by these 
patients. In a word, the patient should be removed from the con- 
ditions and surrounding's which oriffinallv induced the infection. 

The medical treatment is limited to the exhibition of such tonics as 
iron, Fowler's solution, and strychnine. The intestines should receive 
attention during the administration of iron. Fowler's solution gives 
better results in pyogenic lymphadenitis than in the tuberculous form. 
The syrup of ferric iodide in full doses has a tonic effect on the 
mucous membranes. Baginsky advises the exhibition of preparations 
of thyroid gland. I have not seen any markedly good results 
obtained by this method of treatment. 

Cod-liver oil is of great value in this disease. In the form of 
emulsions it should be given in full doses ; with young children its 
use must sometimes be suspended on account of the laxative effect 
on the intestines. 

The local skin lesions should receive appropriate treatment, as 
should also the bones, joints, and suppurating lymph-nodes. It is not 
within the province of this work to enter upon the surgical details of 
such treatment. 

TUBERCULOSIS. 

Etiology. — The essential cause of tuberculosis is the tubercle 
bacillus. This micro-organism gains entrance to the body through 
the respiratory channels (inhalations), the intestinal canal, and 
through wounds. The air in ill-ventilated rooms occupied by tuber- 
culous individuals may at times contain the bacillus in particles of 
dried sputum. Any abrasion of the mucous membrane of the res- 
piratory tract affords opportunities for the entrance of the bacillus 
into the blood and lymph-channels. Among cases of this kind 
belong those in which phthisical individuals have breathed into the 
mouths of asphyxiated infants or children. 

Xot much importance is attached by certain authors to the possi- 
bility of infection through the intestinal canal (Baumgarten, Boll- 
inger). However, cases have been reported in which infected cows' 
milk has caused tuberculosis in infants (Leonhardt, Sonntag, Eber). 
Infection in this manner is rare, because the food of infants (milk) 
is as a rule heated before it is taken into the stomach. 

16 



242 THE SPECIFIC INFECTIOUS DISEASES. 

In a recent monograph Blackader says that of 125 autopsies on 
tuberculous children Northrup found that in 88 cases the primary 
infection had occurred through the respiratory tract. In 3 cases the 
pathway of infection was the intestinal canal, and in 35 cases the 
primary seat of infection remained undetermined. Of 75 additional 
autopsies, Bovaird found the primary lesion in the lungs or bronchial 
nodes in 60 cases. English writers, according to Blackader, place 
the frequency of primary infection through the intestinal tract 
at a much higher figure (25 to 30 per cent.) than do American 
investigators. 

Still, of Great Ormond Street, gives the following statistics of 
primary tuberculosis in infants and children : 

Lung 105 \ -.oo 1 



Probably lung 33 



138 



it-- ' q \ r 153=57 per cent. 

Probably ear 6 / i0 J 

Intestine 53 S ao 00 A 

Probably intestine 10 } 6 3=23.4 per cent. 

Bones, etc 5 ] 

Fauces 2 V 53=nearly 20 per cent. 

Uncertain 46 J 



German pathologists maintain that primary tuberculosis of the 
intestinal canal is rare. Marfan, the French pediatrist, places the 
frequency of primary intestinal tuberculosis at 87 per cent. 

In general, it may be said that the avenue of infection in infants 
and children is through the respiratory tract. Infection through 
infected milk is now believed to be very rare. The importance 
of this mode of infection has been heretofore much exaggerated 
(Blackader). 

Infection through mother's milk has been recorded as occurring 
in the newborn infant (Roger and Gamier). Heredity only creates 
predisposition to the disease, as it does with adults. Dennig found 
that 58 per cent, of his cases of tuberculosis occurred in children of 
tuberculous families. 

Infection through wounds is very uncommon with children, be- 
cause they are not usually exposed to traumatism. It is not so 
likely to result in general tuberculosis as infection through the other 
channels. This is proved by the fact that in the adult so-called au- 
topsy tubercle rarely tends to general infection. Infants w r ho are 
subjected to ritual circumcision are exposed to infection through the 
practice of arresting the resulting hemorrhage by mouth suction. 
I have seen eight instances of such infection. In these cases there 
is a primary enlargement of the inguinal lymph-nodes before the 
process becomes general. The vertebrse may become tuberculous 
or meningitis of a tuberculous nature may result. 

Tuberculosis may be conveyed to the foetus either through the 
placenta, through the spermatozoon, or the ovum of the mother. 



PULMOXARY TUBERCULOSIS. 243 

Under placental infection are to be included those cases in which 
the tubercle bacillus has been found in the blood of the foetus with- 
out accompanying changes in the organs (Schmorl), and those in 
which tubercle nodules and enlarged lymph-nodes have been found 
at birth (Landouzy and Lehman). In both these forms of tubercu- 
lous infection the mother had suffered from acute miliary tuber- 
culosis. The spermatozoon and testis may contain tubercle bacilli 
in the absence of gross tuberculous lesions of the organ (Xakarai 
and Kockel). Tuberculosis may in this way be conveyed into 
the uterus at the time of conception. Jahni and Weigert found 
tubercle bacilli also in the Fallopian tubes of women dying of phthisis, 
although there were no gross changes in the tubes. The ovum may 
thus convey tubercle bacilli. As a rule the bacilli thus introduced 
into the ovum of the fcetus are dormant during intra-uterine life. 
They may develop at any period after birth (Baumgarten). Addi- 
tional facts supporting the theory of intra-uterine infection of the 
foetus have been reported by Baumgarten and Roloff, who found 
a cheesy nodule in a dead-born foetus, and by Birch-Hi rschfeld and 
Bugge, who found bacilli in the blood of a fcetus born of a tubercu- 
lous parent. In 45 per cent, of the infants born in the Bohemian 
Foundling Asylum, tuberculous lesions were present to such a degree 
that the congenital nature of the affection was unmistakable (Houl). 

The infectious diseases play an important role as predisposing 
factors in tuberculosis. Measles, scarlet fever, pertussis, and influ- 
enza, by lessening the resistance of the economy and impairing the 
integrity of the air-passages, favor the infection. Tuberculous 
bronchopneumonia occurs under these conditions, either because the 
tubercle bacillus was present in the body before the infection was 
contracted or gained access subsequently (Frankel). In the majoritv 
of cases the former condition is the rule. Cold, unhygienic surround- 
ings, and poor food, all predispose to infection as with adults. 

The frequency of the occurrence of tuberculosis in infancy and 
childhood varies with the environment. Statistics are therefore onlv 
relative. Seidl found that of 646 consecutive autopsies upon chil- 
dren, 14 per cent, were tuberculous. Forty-five per cent, of all the 

a of tuberculosis occur during the first two years of life, 25 per 
cent, of the total number occur during the first year, and 71 per 
cent, during the first five years (Queyrat, Lannelongue, Dennig). 
It is slightly more frequent among girls than boys. 

Pulmonary Tuberculosis. 

9 -nty per cent, of the infants and children who die from tuber- 
culosis show lung-chang<.- (Dennig). Infection first occurs through 
the respiratory tract. A cheesy lymph-node may burst into the 
bronchi, and bacilli may thus gain access to the lung alveoli and 



244 THE SPECIFIC INFECTIOUS DISEASES. 

cause changes, as they do in the adult lung. Hematogenous infec- 
tion occurs through the bursting of a small tuberculous nodule 
into a bloodvessel, thus flooding the lung with infectious matter, or 
by the carrying of minute emboli of this material to distant parts 
of the lung. 

Tuberculous bronchial lymph-nodes, bone, and pleura may also 
give rise to infection of the lung through the lymph-channels. 
The part played by the infectious diseases in its dissemination has 
been already mentioned. 

Morbid Anatomy. — The three principal forms of tuberculosis 
of the lungs which occur in infants and children are : 

The miliary form, which is characterized by the eruption of miliary 
tubercles throughout the lung. The lung is on section found to be 
dark red, hypersemic, and to contain less air than the normal lung. 
The bronchial mucous membrane is hypersernic and covered with 
blood and mucus. 

The cheesy or cheesy ulcerative form, also called florid phthisis, takes 
the form of cheesy lobar or lobular pneumonia. In recent cases the 
lung is grayish red, and there are areas which rapidly become cheesy, 
and are not encapsulated. These may coalesce, involving the greater 
part of a lobe in the process. Small cavities are frequent, large ones 
rare. The cheesy ulcerative form occurs as a result of the aspiration 
of large numbers of tubercle bacilli. 

The chronic form, which is a cheesy fibrous bronchopneumonia, is 
essentially a tuberculous bronchopneumonia. Round cheesy nodules 
are found surrounded by a fibrocellular zone resulting from the destruc- 
tion of extensive areas of lung-tissue. The pulmonary pleura is 
thickened. The bloodvessels participate in the process. There is 
endarteritis with miliary tubercle in the walls of the bloodvessels, and 
there may be thrombosis. The tubercles may burst into the interior 
of the bloodvessels. The bronchi, trachea, and larynx may be 
affected. There are ulcerations of the mucous membrane and 
destruction of cartilage. The bronchial lymph-nodes or glands are 
enlarged and infected in most cases of tuberculosis of the lungs in 
children. Henoch has, however, shown that the bronchial nodes 
may be tuberculous and greatly enlarged without involvement of the 
lung-tissues. Northrup found the bronchial lymph-nodes affected 
in 125 consecutive autopsies. The whole node is converted into a 
cheesy mass, which may soften and break down. If there is a 
perforation into a bronchus, masses of bacilli may be discharged 
into the lung. Perforation into the bloodvessels may also occur. 
The nodes may form small masses or large mediastinal tumors at 
the root of the lung. 

Localization. — The apices of the lungs of infants and children are 
not as in adults the region most frequently affected by tuberculosis. 
The first change may appear in the lower lobe or the lower portion 



PULMONARY TUBERCULOSIS. 245 

of the upper lobe, and spread thence. This is accounted for by the 
miliary character of the affection in the lungs of infants and children 
(Rindfleisch), and also by the fact that in many cases the process 
spreads from the bronchial nodes or glands to adjacent parts 
(Weigert). 

The symptoms of tuberculosis of the lungs in infants and young 
children are not so characteristic as in the adult, nor is there a 
gradual development of the symptoms pointing to involvement of 
the lungs. After the fifth year of life the symptoms closely resem- 
ble those seen in the adult. As regards infants, we shall describe 
only clinical types of the disease. Even these exhibit many varie- 
ties. 

Henoch has described forms of tuberculosis in infants which 
closely resemble cases of marasmus due to gastro-enteric disease. 
In many of them there are steady emaciation and progressive 
muscular weakness ; the infant lies helpless ; the abdomen is re- 
tracted ; the eyes may present a conjunctivitis ; the cervical, axillary, 
and inguinal glands may be slightly enlarged ; there is constipation 
alternating with diarrhoea ; the skin is easily inflamed and abscesses 
may form. In the terminal period vomiting sets in. The lungs 
throughout the course of the disease may present few signs, or there 
may be evidences of a general bronchitis. In these slowly emaci- 
atiug infants there is no cough of sufficient severity to indicate 
involvement of the lung. The terminal stage may present cerebral 
symptoms of a mild type, such as rigidity of the neck, with periods 
of stupidity alternating with irritability. The infants die with 
a progressive loss of flesh and strength. The temperature is for 
days normal or a little above normal. In other types the dis- 
ease is masked by an acute or subacute bronchopneumonia. In 
these cases the infant, after suffering from exposure or some infec- 
tious disease, suddenly exhibits all the signs of a bronchopneumonia. 
There are severe cough, high temperature, dyspnoea, and cyanosis, as 
in the ordinary bronchopneumonia. Death may ensue in a few days 
or in a week. In other forms fatal results take place after sev- 
eral weeks, with symptoms closely resembling those of a persistent 
bronchopneumonia of the ordinary non-tuberculous variety. In 
other case- the symptoms of an acute bronchopneumonia are present, 
sometimes complicated with empyema. Evacuation of the pus is 
followed by apparent improvement, and the empyema may even heal, 
but the infant or child gradually emaciates, and the cough, which may 
have abated, become- aggravated. Examination of the chest reveals 
new areas of lung involvement. In these cases the pus does not 
always contain the tubercle bacilli. The empyema may be the result 
of mixed infection, and the pus may contain only simple streptococci, 
the physician being frequently misled as to the true condition. 
Many forms of tuberculosis of the lungs in infants and children 



246 THE SPECIFIC INFECTIOUS DISEASES. 

cause death with the terminal symptoms of tuberculous meningitis. 
Especially characteristic in older children, as compared with the 
adult, are those cases of tuberculosis of the lung which follow some 
slight injury, blow, or exposure, and in which there are for weeks 
no signs in the lung or elsewhere to account for the gradual emacia- 
tion and intermittent or remittent temperature. After a variable 
length of time signs of involvement are detected at one apex, or 
posteriorly over the base or mid-area of the lung. Even then 
the cough may be absent and no sputum be expectorated. The 
child then has intervals of stupidity ; there is delirium at night 
accompanied by the typical hydrocephalic cry. Irritability of tem- 
per is marked, the emaciation is very rapid, and coma and death 
with terminal paralyses show that the infection has involved the 
cerebral meninges. 

The temperature is irregular in course. It may be normal for 
a few days, after which it rises one or two degrees daily in the 
afternoon and falls to the normal toward morning. 

Haemoptysis is very rare in infants. Henoch has seen 3 cases 
in young infants and 1 in a child of two years. Acker has reported 
a case in a child of three years. I have seen several cases in chil- 
dren of more than six years of age. 

Sputum. — Infants do not expectorate. At most a frothy mucus 
collects around the orifice of the mouth after a coughing spell. 
Even older children expectorate very little, and must be taught to 
do so. 

Course. — Up to the second year of life, the course of tuber- 
culosis of the lung is generally acute (Henoch). The disease may 
pursue a subacute course, but it is rarely as prolonged as in the 
adult. In children above the fifth year its course closely resembles 
that taken in the adult. 

The diagnosis of tuberculosis of the lung in infancy and early 
childhood must, for the most part, be made from the history of the 
case. In many of the cases the physical signs in no way differ 
from those seen in n on -tuberculous diseases. Cases in which 
marked consolidation of the lung persists, with progressive emacia- 
tion, and cases in which auscultation reveals the presence of cavities, 
are certainly suspicious. There is no reliable method of deter- 
mining the nature of an acutely developing bronchopneumonia ; 
the detection of the tubercle bacillus in the vomit, in the feces, or in 
the exudate of a complicating pleurisy or empyema, is of diagnostic 
aid. The use of tuberculin as a diagnostic agent has not met with 
the approval of the profession. 

The existence of enlarged lymph-nodes in the mediastinum or the 
root of the lung is, according to some authors, revealed by symp- 
toms of pressure. Pressure on the bronchi may give rise to dysp- 
noea ; on the large veins, to nervous congestion and cyanosis, or 



TUBERCULOSIS OF THE PERITONEUM. 247 

oedema of the lungs ; on the recurrent laryngeal nerves, to asthma 
or laryngospasm ; on the oesophagus to dysphagia. Although in 
exceptional cases such symptoms may be thus correctly interpreted, 
I believe with Henoch that diagnosis of these enlarged nodes during 
life is highly uncertain. 

Treatment. — From a study of the symptomatology it will be 
seen that the treatment of tuberculosis of the lung in young infants 
and children must be simply symptomatic. A case of suspected 
tuberculosis should be isolated from other children. The fever 
needs little attention if it remains low ; if high, it is treated as in a 
case of simple bronchopneumonia. The cough and restlessness are 
also treated symptomatically. 

Tuberculosis of the Peritoneum. 

(Tuberculous Peritonitis.) 

Occurrence. — According to the statistics of Dennig, Muller, 
Biedert, and Simmonds, tuberculous peritonitis occurs in from 8 to 
21 per cent, of all the cases of tuberculous disease. Sixty -five per 
cent, of the cases operated on by Herzfeld were under the age of 
fifteen years. The frequency varies in different localities. The 
figures given by different authors vary with the nature of the mate- 
rial utilized for statistical purposes. 

Etiology. — Tuberculous peritonitis is rarely if ever primary, 
although such cases have been described by Henoch and Muller. 
The peritoneum may become infected through the blood-channels 
(hematogenous) ; under these conditions tuberculosis of the perito- 
neum is simply a feature of the manifestation of acute miliary 
tuberculosis. The peritoneum may become infected through the 
lymphatics or lymph-channels (lymphogenous). Under these con- 
ditions it is the result of infection from adjacent organs, such as the 
intestines, the genito-urinary tract, the mesenteric, peritoneal, or 
retroperitoneal lymph-nodes, and the vertebra? and pleura. 

Morbid Anatomy. — There are, according to Herzfeld, three 
main forms of tuberculous peritonitis : the miliary, submiliary or 
exudative form ; the nodular or sclerosing form ; and the adhesive 
form. 

The Miliary, Submiliary, and Exudative Form. — In this form there 
is an eruption on the peritoneal surface, of gray, transparent tubercles 
of varying sizes. The intestinal coils are covered with fibrin, and 
are slightly adherent to one another. There is a clear serous, sero- 
fibrinous, seropurulent, or even ichorous exudate (mixed infection). 

The Nodular or Sclerosing Form. — In this form the quantity of 
the exudate in the abdominal cavity is small. The omentum is 
converted into a solid cylindrical mass, containing tumors of a tuber- 
culous nature as large as an apple. The mesentery is thickened and 



248 



THE SPECIFIC INFECTIOUS DISEASES. 



covered with tubercles. The intestinal wall is thickened and covered 
with gray or grayish-yellow tubercles, which may attain the size of 
tumors. The coils of gut are adherent, and the whole peritoneal 
cavity may be obliterated. 

The Adhesive Form. — In this form the intestines form an adherent 
mass, with masses of exudate between the coils of gut, forming 
pseudocysts. This exudate may be of a puriform nature. Aggre- 
gations of tubercles between the 4 coils of gut break down and perfor- 
ate into the gut, or become adherent to the abdominal wall and 
perforate externally forming intestinal or abdominal fistulse. Per- 
foration may thus occur in the absence of any real ulceration on the 
mucous membrane of the gut. 

In addition to the above principal forms of tuberculous perito- 
nitis, mixed forms occur. 

The exudate in the peritoneal cavity may be purely serous 
(ascites), or the serum may, as in a case which I observed, have 
a chylous appearance, due to the admixture of fat. In other 
forms the exudate may be seropurulent, hemorrhagic, or, in mixed 
infections, putrid. In the purely ascitic variety the fluid is free ; in 
the purulent form, it is frequently sacculated between the adhesions 
on the coils of gut. 

Symptoms. — The disease is, as a rule, insidious and slow in 
development. The stage of abdominal distention has usually been 





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Tuberculous peritonitis. Female child, five years of age. Ten days of her temperature 
immediately preceding operation (laparotomy). 

reached when the patient is first brought to the physician. The 
history shows that the child has been for some time gradually losing 
weight, that the appetite is capricious, and that there have been 
attacks of abdominal pain. This pain may be localized or radiate 
from one point, may be constant, or may resemble visceral neuralgia. 
Sometimes there is no history of pain, but it may be detected by 
pressure on parts of the abdomen. There may be a slight rise 
of temperature toward evening (Fig. 67) ; diarrhoea may alternate 
with constipation. The abdominal distention is the leading feature. It 
may take the form of a uniform ascitic accumulation (Fig. 68) ; the 
surface of the abdomen may be uneven and irregular, and tumors 
with cvstic formation mav be felt through the abdominal walls. 



TCEERCCLOSIS OF THE PEEITOSEUM. 



249 



Fig. 



The movements, which are rich in fat, sometimes resemble icteric 
evacuations. This condition was formerly considered pathognomonic 
of tuberculous peritonitis (Biedert, Conitzer). 

Vomiting of fecal or biliary matter resembling that seen in 
appendicitis may occur. 

In marked contrast with these is a form which in its acute onset 
may simulate acute perforative peritonitis. In this variety the 
tubercle mass may cause perforation 
either of the appendix or the gut in 
its cavity. Symptoms of acute per- 
forative peritonitis which in every 
way resemble those of appendicitis set 
in. It is only by resort to laparo- 
tomy that the nature of the affection 
can be discovered. 

Physical Signs. — The physical 
signs in the miliary and the nodular 
forms are due to the presence of free 
fluid in the abdominal cavity. If 
ascites is present, there will be the 
percussion-wave, the flatness in the 
flanks, and change of the tympanitic 
area will occur with change in the 
position of the patient. If adhesions 
are present and there are encapsula- 
tions of fluid, the signs will not vary 
on changing the position of the pa- 
tient. On the other hand, in the 
adhesive form there will be evidences 
of tumor masses in the abdominal 
cavity, cystic formations caused by 
the encapsulated exudate, and little 
or no fluid. 

In cases of adhesions in tuber- 
culous peritonitis of the miliary form, 
the fact that when the patient is in 
the recumbent position the coils of gut may here and there be seen 
outlined over the abdominal parietes, is of diagnostic value ( Fig. 
69). I was able by this means to confirm the diagnosis of adhe- 
sions in one such ease, and have detected them clinically in other 
cases in which this form <>f peritonitis had been diagnosed. 

The liver may be enlarged as a result of amyloid degeneration or 
tuberculous interstitial hepatitis. 

The spleen may be enlarged as a result of amyloid degeneration. 

Rectal examination may reveal miliary nodules or peritoneal 
masses palpable through the walls of the rectum. 




Uniform abdominal distention due 
to ascites of tuberculous peritonitis ; 
enlarged spleen. 



250 



THE SPECIFIC INFECTIOUS DISEASES. 



The diagnosis is based on the slow and insidious onset, the 
colicky abdominal pains, abdominal tenderness on palpation, the 
presence of ascites or tumor masses, constipation alternating 
with diarrhoea, progressive loss of strength, intermittent fever or 
slight rise of temperature in the evenings, and the presence of 
tuberculosis in other organs. At the outset tuberculous infection in 
other parts of the body may be difficult of detection. A rectal ex- 
amination should always be made. This form of peritonitis should 
be differentiated from the non-tuberculous form. Inasmuch as some 
authors, notably Unger and Nothnagel, doubt the occurrence of 



Fig. 69. 




Tuberculous peritonitis, miliary form, female child, five years of age. Irregular contour of 
abdominal parietes in the recumbent posture, showing intestinal agglutination. 

idiopathic non-tuberculous peritonitis, caution should be exercised in 
making a diagnosis of simple chronic peritonitis. Absence of ema- 
ciation and retrogression of symptoms by no means prove that the 



OTHER FORMS OF TUBERCULOSIS. 251 

disease may not have been tuberculous, since some forms of tuber- 
culosis of the peritoneum present such peculiarities. 

This form of peritonitis must also be differentiated from cirrhosis 
of the liver, new growths, cardiac and renal affections. 

Course. — The course of the disease is chrome. Frequently the 
symptoms retrograde and there is an apparent recovery. The ascites 
may at times diminish, and again increase. The chronic forms 
unless operated upon lead to the formation of abdominal fistula?, to 
perforative peritonitis, to tuberculosis of the organs, and to amyloid 
degeneration of the liver and spleen, with emaciation, exhaustion, 
and death. 

Treatment. — Laparotomy, when advanced tuberculosis in other 
organs is not present, is, according to Herzfeld, curative iu 54 
per cent, of cases. In a series of 29 cases of all ages operated upon 
by him, 19 were under the age of fifteen years. With operative 
treatment must also be combined the medicinal and hygienic treat- 
ment suitable to cases of pulmonary or local tuberculosis. On the 
other hand, in the forms which resemble cases of tabes meseraica, 
in which emaciation and cachexia are present before much exudate 
is formed, it is difficult to decide as to the propriety of operative 
measures, especially if diarrhoea be present. In these cases if the 
diagnosis is not certain, proper feeding should be begun and the con- 
dition of the patient improved before laparotomy is attempted. 

Simple Chronic Peritonitis. 

Although Henoch and Miiller have reported cases of chronic 
idiopathic non-tuberculous peritonitis, its occurrence is still a matter 
of dispute. Nothnagel, Unger, and Heubner, while not denying in 
toto its possible occurrence, insist on its extreme rarity. The absence 
in these cases of progressive emaciation is no proof of the non- 
tuberculous nature of the affection. The absence of the tubercle 
bacillus in the abdominal exudate is of slight diagnostic value. In 
29 cases of undoubted tuberculosis of the peritoneum Herzfeld found 
the bacillus only once in the ascitic fluid. In some forms of tuber- 
culous peritonitis the nutrition may not only be good, but there 
may be no history of heredity or scrofulosis. It is manifest that 
under these conditions it is impossible to describe a disease the 
existence of which is still in doubt. 

Other Forms of Tuberculosis. 

Tuberculosis of the larynx is rare in children. It occurs in 
from 3 to 4 per cent, of the total number of eases of tuberculosis 
(Reiner, Steffen, Barthez, Rilliet). Demme has reported a ease in a 
child of four and one-half years. 

Tuberculosis of the Pleura and Pericardium. — Primary 



252 THE SPECIFIC INFECTIOUS DISEASES. 

tuberculosis of the pleura is rare. Dennig reports that it occurred 
as a feature of general tuberculosis in 14 per cent, of his cases. 
Pericarditis of the tuberculous variety occurs in only 3 per cent, of 
the cases of general tuberculosis. 

Tuberculosis of the heart muscle is very uncommon. Sanger 
reports a case in a child of nine months, and Demme one in a 
patient of live years. The endocardium may be involved in general 
tuberculosis (Perroud). 

Abdominal Tuberculosis. 

The following table, showing the relative frequency of tuberculous 
involvement of the abdominal viscera, is taken from Dennig' s figures : 

Peritoneum. Stomach and Mesenteric 

intestines. lymph-nodes. 

Dennig 8 per cent. 14 per cent. 21 per cent. 

Miiller 18 " 38 " 57 

Biedert 18 " 31 •« 40 " 

Simmonds 21 " 31 " 53 " 



Tuberculous Meningitis. 

(Acute Internal Hydrocephalus ; Basilar Meningitis.) 

Occurrence. — Tuberculous meningitis has been observed in 
infants as early as the third month (Steffen). Barthez and Rilliet 
have seen cases in infants five months old. The frequency of tuber- 
culous meningitis varies w r ith the locality. Dennig places the fre- 
quency of tuberculous meningitis among children who suffer from 
tuberculous disease at 60 per cent., while Medin found this form of 
meningitis in 15 per cent, of tuberculous children. It is most fre- 
quent in the nursing period ; 75 per cent, of all cases occur under 
the fifth year. The second year of infancy shows the greatest num- 
ber of cases (Steffen). It is more frequent among male than female 
children. 

Etiology and Morbid Anatomy. — Exposure to cold and trau- 
matism predispose to the affection. In many cases there is, in addition 
to the meningeal disease, disseminated tuberculosis of the lungs, 
pleura, spleen, liver, and peritoneum. In other cases the meninges are 
the chief seat of the disease, only a few isolated foci of tuberculosis 
being present elsewhere, as in the mesenteric or bronchial lymph- 
nodes. It is rare to find the lesions confined to the meninges, 
and some authors deny the possibility of such a condition. It is 
not always possible to determine the primary focus of infection. 

The tubercle bacilli, which are the causative factors, may be 
carried by the blood (hsematogen) to the meninges, and there give 
rise to a more or less .extensive miliary deposit. The original focus 



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TUBERCULOUS MENINGITIS. 253 

in such cases may have been a choosy lymph-node, a tuberculous 

nodule in the lung, or a carious bone or joint. The tubercle bacilli 
may enter the lymph-channels from an adjacent carious bone of the 
skull, a diseased mastoid, or a spinal vertebra. An ozaena or a soli- 
tary tubercle of the brain may give rise to tuberculous meningitis by 
this mode of transmission. Whatever the focus, at the point of in- 
fection there will result an eruption of tubercles which may remain 
localized or become disseminated along the course of the cerebral 
lymph-channels. When the dissemination of bacilli occurs through 
the blood, miliary tubercles are found in the course of the bloodves- 
sels and in their Avails. The tubercles may remain confined to the 
meninges or may involve the brain-tissue, constituting a meningo- 
encephalitis. In the meshes of the meninges (pia) there is a sero- 
fibrinous or seropurulent exudate, which is also found in the ventricles 
(hydrocephalus), and which infiltrates the brain-tissue itself (men- 
ingo-encephalitis). If the exudate is limited in quantity and the 
tuberculous process is localized, forming one, two, or three nodules, we 
speak of tuberculosis of the brain or solitary tubercles of the brain. 
The tubercles are seen as grayish shining nodules surrounded by a 
hypersemic zone. They vary from microscopic size to large yellow 
nodules, which are of older origin. They may be strung along the 
vessels or break through their walls, forming thrombi with subse- 
quent hemorrhagic infarction. 

The basal branches of the artery of the Sylvian fissure are usually 
the seat of the eruption of these tubercles. The tuberculous process 
is generally bilateral, but one side, usually the left, may alone be 
the seat of disease. Tuberculous meningitis affects by selection 
the base of the brain — hence the term basilar meningitis. The 
convexity may be involved in the process, although it is rarely 
the seat of tuberculous meningitis unless the base of the brain is 
affected. Stetfen and Henoch have described cases of isolated 
tuberculous meningitis of the convexity of one or both sides. The 
base, the vicinity of the pons, and the chiasm are the seats of the 
process. In all forms, the pia is infiltrated with serofibrinous or 
-empurulent exudate. The choroid plexus may be involved. Acute 
hydrocephalus then results. 

The brain-tissue itself is the seat of inflammatory infiltration, 
and the nerves at the base are surrounded with exudate and are in 
process of degeneration. The ependyma of the ventricles (the 
lateral, third and fourth) are the seat of inflammatory thickening and 
eruption of tubercles. These cavities are filled with exudate. The 
meninges of the spinal cord, the cord itself, and the nerves at the 
points of exit are frequently involved in the tuberculous meningitis, 
a- ha- been demonstrated by Leydon, Erl>, and Dennig. The latter 
found the cord involved in !) out of 10 cases. The pia may he in- 
volved to a slight degree. The nerves at the point- of exit are 



254 THE SPECIFIC INFECTIOUS DISEASES. 

involved in inflammatory exudate. The tissue of the cord and the 
nerve-elements may be the seat of degenerative processes. 

The symptoms of tuberculous meningitis cannot be clearly clas- 
sified according to stages. There is an indefinite period of premoni- 
tory symptoms followed rather abruptly by manifestations of cerebral 
irritation, and ending with a period in which pressure-symptoms are 
pronounced. As a rule, the disease is slow of development, although 
cases occur in which the rapid malignant course simulates that seen 
in rapidly fatal cerebrospinal meningitis of the epidemic type. The 
disease gives a varying clinical picture in the different periods of 
childhood. The infant of from seven to twelve months refuses to 
nurse, has a low fever, and may have diarrhoea alternating with 
obstinate constipation. The illness of an infant is often attributed 
to a fall occurring while it was learning to walk. A weakness 
of the extremities is thus indicated. The infant becomes indifferent 
to its surroundings and passes into a somnolent condition. Emacia- 
tion is progressive. Vomiting occurs once or twice daily, the food 
being ejected from the mouth after nursing without apparent effort. 
The vomiting may be followed by a convulsion, after which the 
infant becomes unconscious. There may be strabismus, or rigidity 
of the extremities, or the extremities may be in constant motion of an 
automatic character. The convulsions may follow one another with- 
out cessation. These symptoms may set in after a period of one, two, 
or five weeks of ailing. In other cases the infant may have suffered 
from a chronic otorrhoea, although otherwise in apparent health. 
Suddenly, vomiting followed by a convulsion sets in. This convul- 
sion is the forerunner of symptoms, such as coma, which denote that 
the disease has become established without having attracted the 
notice of the parents. In children of five years of age the symptoms 
are more marked. The child may have an attack of vomiting and 
diarrhoea and apparently recover ; after a few weeks, during which 
there are irritability, loss of appetite, and progressive emaciation, the 
child no longer desires to be up and about, but lies quiet in its crib, 
with its head in a characteristic rigid position. It develops strabismus, 
becomes soporose, and cries out at night. This cry is sometimes pierc- 
ing in character, and is the cause of much concern to the mother. When 
the symptoms of cerebral pressure are fully developed, the picture is 
in the majority of cases much the same. The infant after the first con- 
vulsion lies in a soporose or comatose condition. The eyes are open 
and there is a vacant stare ; the sclera may be apparent above the 
cornea ; the fontanelle if still open is tense and bulging, and there 
may be horizontal nystagmus. The infant cries if disturbed, or may 
be indifferent to its surroundings. The pupils may be unequal in size 
and react to light. In one case which I observed the pressure- 
symptoms were extreme. The infant lay on its back with rigid neck 
and arched back (opisthotonos), and emitted a piercing cry at in- 



TUBERCULOUS MENINGITIS. 255 

tervals. At each cry the pupils became successively dilated and 
contracted (hippus). I have seen this phenomenon in two cases 
of tuberculous meningitis. Opisthotonos may be present, and the 
retraction of the head may relax at intervals, the muscles of the 
back being lax. In some cases there is apparently no rigidity of the 
neck. As a rule there are no convulsions. As the infant or child 
lies quietly in its crib the inspirations during the stage of cerebral 
pressure may be very irregular or may be of the Cheyne-Stokes 
type. The outline of the abdomen is at first normal or there may 
be a slight retraction at the upper part. The abdominal wall 
may be quite lax, so that the coils of gut can be made out. If 

Fig. 70. 




Babinski's reflex. Tuberculous meningitis ; stage of facial palsies. Boy, seven years of age. 

the case is protracted, retraction of the abdomen occurs in the 
final stages of the disease. This condition has been described 
as the boat-like abdomen. It is not diagnostic of this form of 
meningitis. 

In rare cases spastic symptoms closely resembling those of tetany 
occur after the initial convulsion. The infant lies comatose, with 
rigidly flexed arms ; the Chvostek and Trousseau symptoms are 
present. In all of these cases, if the skin is stroked with the finger 
ever so lightly, a red mark appears over the stroked area (tache cere- 
brale). In the spastic eases the knee-reflexes may be increased, but 
in the non-spastic case- they are diminished. It is difficult to elicit 
Kernig's symptom in spastic cases, because the infants lie with the 



256 



THE SPECIFIC INFECTIOUS DISEASES. 









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knees flexed. By straighten- 
ing the legs and thighs it is 
possible in the majority of 
children to obtain the symp- 
tom. 

The most important symp- 
toms of the final stage of 
tuberculous meningitis, both 
in infants and older children, 
are the localized facial palsies. 
For several days or weeks 
preceding the fatal issue, one 
side of the face is seen to be 
flatter than the other. There 
may be ptosis or lagophthal- 
mus of the eyelids. One eye 
may be rotated internally, 
owing to paralysis of the 
abducens. The extremities 
are also paretic. The arm 
and leg of one side may be 
rigid or flexed, while those 
of the opposite side are lax. 
Irritation of the soles of the 
feet may give a Babinski re- 
action (Fig. 70). In some 
cases this reaction is present 
independently of any irrita- 
tion of the plantar surface. 
Toward the end, convulsive 
twitchings appear in the 
muscles of one or the other 
side of the face or of the ex- 
tremities. Death supervenes 
in coma with convulsions. 
The heart may continue to 
beat for some time after the 
cessation of respiration. 

Children from six to nine 
years of age present a more 
decided clinical picture in 
the premonitory stage. For 
some weeks before the onset 
of symptoms of irritation 
they complain of headaches, 
frontal, sincipital, or parietal. 



TUBERCULOUS MENINGITIS. 



257 



The patient is listless, walks with an unsteady gait, and has no 
desire to study or play. A discharge from the ear may have 
been present for months before the onset of these symptoms. In 
one ease the child had for some time complained of pain in the 
left side of the chest and had lost weight steadily. There were 
mild pleurisy and signs of slight consolidation at the apex of 
the left luncr. There was daily elevation of a few decrees of tem- 
perature in the evening, and a normal temperature in the morning. 
In this case, although there were distinct signs of pulmonary 
involvement of a mild type, the emaciation was progressive and 
the leucocyte counts low (8000 W.B.C.). At night the typical 
cry of tuberculous meningitis was present. In the early stages 
of the disease the patient was conscious during the day, but later 
became listless, irritable, and slept or was drowsy during the day. 

Fig. 72. 



DAY OF 
ILLNESS 


1 


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Tuberculous meningitis, observed from the outset of the symptoms. Female infant, fourteen 

months old. 



When questioned, a slow stupid answer was given. The child vomited 
and at times became nauseated. The Kernig symptom appeared. 
Right lagophthalmoa was present. The pupils were unequal in size, 
the left being dilated. The pulse at this time varied from 60 to 
100 and was compressible. Finally, coma set in with left facial 
palsy and convulsive twitehings of the left side of the face. This 
was for three months under constant observation. In other 
- the vomiting is rapidly followed by paralytic symptoms such 
as ptosis and facial paralysis on the same side. There are no convul- 
sions and no cry, but there is rigidity of the neck and extremities ; 
one patellar reflex may be absent. The Kernig symptom and 
Babinski reflex are present in the majority of eases in children. 

17 



258 



THE SPECIFIC INFECTIOUS DISEASES. 



The very rapid and fatal cases of tuberculous meningitis have 
I icon described by Osier and Dennig. In these the organism is 
overwhelmed by the toxaemia of the disease, no marked tuberculous 
lesion being present in any organ but the brain. A patient in 
apparently good health is suddenly seized with convulsions followed 
by a period of unconsciousness. There are muscular relaxation and 
a vacant stare. The convulsions may be repeated at intervals of a 
few minutes or half an hour. There then follow opisthotonos and 
spasms, and the abdomen is tympanitic. There is neither vomiting, 
tache, nor elevation of temperature. There are spastic contractures of 
the extremities alternating with relaxations. Death occurs in a con- 
vulsive seizure within ten hours. These cases are exceedingly rare. 

The temperature-curve in tuberculous meningitis is not charac- 
teristic. In some cases the temperature will not rise more than a 

Fig. 73. 



illness 3C 37 38 39 40 


HuUR 3 6 9 12 3 6 9 '12 3 G 9 12 3 G 9 12 3 6 9 12 3 6 9 12 3 6 9 12 3 6 9 12 3 6 9 12 


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RESP. ?iS^55SS^S5S33i52r ss^SSiJ 35;5So ( o3 



Tuberculous meningitis ; general miliary tuberculosis ; terminal stage ; coma and paralysis. 

Boy, seven years of age. 

degree or two above the normal, intermitting to the normal or nearly 
so. In other cases it may be normal for days, then rise a degree or 
more, rarely above 103° F. (39.4° C), and then fall again to the 
normal. In cases in which there is a general miliary process the 
temperature mounts to 105°-106° F. (40.5°-41.1° C.) or higher 
toward the close. The fatal issue in other cases occurs with a sub- 
normal temperature (96° F., 35.5° C.) lasting for a day or more be- 
fore death. If the case is a protracted one, the normal diurnal varia- 
tions may be reversed — that is to say, the highest temperature may 



TUBERCULOUS MENINGITIS. 259 

be reached in the morning hours and the lowest toward evening. 
In the majority of cases, however, the temperature is rarely higher 
than 103°' F. '(30.4° C). 

The pulse is increased at the onset, but during the course of the 
disease becomes slow and may range from GO to 100 or more during 
the twenty-four hours. 

The respirations are irregular, and may vary from 18 to 60 with- 
in the twenty-four hours, even if no pulmonary lesion is present. 

The diagnosis of tuberculous meningitis is based upon the history, 
the general symptomatology, and the results of lumbar puncture. A 
history of tuberculosis in the father or mother or the presence of a 
tuberculous focus is significant. Chronic otitis, disease of the bones 
or joints, and signs of lung involvement are of value. The lung 
will in some cases show a general bronchitis (tuberculous miliary 
process) or an area of apex consolidation. In other cases, especially 
in young infants, the lung may present no physical signs. 

General Symptoms. — Of great value is the slow insidious onset, 
followed abruptly by vomiting and convulsions with subsequent un- 
consciousness. 

Vomiting sets in on the average eighteen days before the fatal 
issue and after the onset of premonitory symptoms, and may occur 
once or twice daily. It is absent in some cases. Localized con- 
vulsions may appear two weeks after the initial attack of vomiting. 

These symptoms in infants and young children in association with 
a fever of slight or moderate intensity, and bulging of the fontanelle 
(if it is still open), are valuable aids to diagnosis. 

The slow, irregular pulse and the respiratory phenomena are pres- 
ent in other forms of meningitis. The cerebral cry (cries hydroceph- 
alique) is of confirmatory value only. The emaciation and retracted 
abdomen, as well as the opisthotonos and the bulging fontanelle, may 
be present in other forms of meningitis, such as the cerebrospinal 
meningitis of the epidemic type, and especially in that form described 
by English authorities as posterior basic meningitis. The symptoms 
of optic neuritis are present in cerebrospinal meningitis as well as 
in the tuberculous form. In the latter, they are sometimes absent. 

The choroid is sometimes the seat of tubercle deposit. Choroid 
tubercle was seen during life in 3 out of 30 of my cases. 

Of great service in making a clinical diagnosis is the presence of 
palsies of the cranial nerves. Ptosis, facial paralysis, strabismus, 
paralysis of the internal rectus of one side, or ptosis on one side 
and lagophthalmus on the opposite side, are indicative of a lesion 
at the base of the brain. These palsies are seen much more fre- 
quently in the tuberculous forms of meningitis than in cerebrospinal 
meningitis of the epidemic type. J have, however, seen them in cases 
of cerebrospinal meningitis in infants under the age of twelve months. 
If the lateral ventricle is distended with fluid, the hollow note 



260 THE SPECIFIC INFECTIOUS DISEASES. 

described by Macewen may be elicited by percussion along the 
parietal or frontal bone. As the infant lies in bed with the head 
supported on its side the note is best obtained by gentle percussion 
on the frontal or parietal bone lying interiorly. It may also be 
obtained on the superior frontal or parietal bone. I have found this 
sign of great utility in the early stages of the disease. 

Lumbar puncture is to-day the most valuable aid in making 
a diagnosis of tuberculous meningitis. We must not expect to find 
tubercle bacilli in all fluid withdrawn, for in certain cases they 
are so few in number as to escape detection. In the majority 
of my cases they were present. Furbinger found bacilli in 27 out 
of 37 cases. I have come to look upon certain negative character- 
istics of the puncture fluid as of great value. The fluid is clear or 
shows slight turbidity in strong light, owing to the presence of a 
fine, dust-like formation. The absence of all bacteria or leucocytes 
in these clear or turbid fluids and the formation in the test-tube 
after twenty-four hours of a peculiar funnel-shaped, cobweb-like 
structure, point strongly to the tuberculous nature of the fluid. 

Tuberculous meningitis must be differentiated from epidemic and 
sporadic cerebrospinal meningitis (Weichselbaum), apex pneumonia, 
typhoid fever, sepsis, disturbances of the stomach and gut, uraemia, 
helminthiasis, and disease of the ear. 

The onset of epidemic cerebrospinal meningitis is acute and the 
cerebral symptoms develop rapidly. The fluid obtained by lumbar 
puncture will show the intracellular diplococci even if clear. In the 
majority of cases the fluid is turbid after the fifth day of the disease. 

Pneumonia with cerebral symptoms may simulate tuberculous 
meningitis. Here again the history and the character of the delirium 
in older patients will aid us. The signs in the lung and the presence 
of leucocytosis, which is marked in pneumonia and generally absent 
in tuberculous disease, are significant. I have, however, seen cases 
of tuberculous meningitis with leucocytosis. In the majority of 
cases of typhoid fever the history will be of service in connection 
with the roseola, the Widal reaction, the enlarged spleen, and the 
absence of leucocytosis. Diarrhoea may be present in typhoid. 

Disturbances of the gut, uraemia, and helminthiasis may present 
symptoms resembling those of tuberculous meningitis, but the symp- 
toms in time retrograde or are cleared up by a study of the case. 

I have seen otitis media in nurslings with very limited areas of 
bronchopneumonia, simulate tuberculous meningitis. In these cases 
the infants may have been ill for two weeks or more. They start 
from sleep, are irritable on awakening, and lose appetite. 

In one case the ocular symptoms closely simulated those of tuber- 
culous meningitis. As a rule there are intervals during which the 
child is not only free from pain, but also has a normal temperature. 
At other times the temperature has a septic intermittent character, 



SYPHILIS. 261 

and mounts higher (104° F., 40° C.) than in tuberculous meningitis. 
Aural examination only will remove doubt. 

The duration of the disease varies within wide limits ; I have 
seen eases which extended over three months. The majority of 
cases last from two to three weeks, but cases lasting five weeks are 
not unusual. The very rapid cases in which death ensued within 
twenty-four hours have been mentioned. 

The prognosis is always fatal. Isolated cases of recovery have 
been reported, but should be regarded with doubt. 

The treatment is directed to alleviating the sufferings of the 
patient. Lumbar puncture is not curative, and should not be 
repeated after the first diagnostic puncture has been performed. 

Tuberculosis of the Brain. 

(Solitary Tubercle of the Brain.) 

In this there may be a single localized tuberculous nodule or 
mass in the brain, or several such formations may be present. 
Demme found a growth of this kind in an infant twenty-three days 
old. Henoch has published a case in an infant eleven days old. The 
majority of cases occur between the second and the fifth year. 

Morbid Anatomy. — Tubercle bacilli of diminished virulence 
and limited number are carried from the focus of tuberculosis to the 
brain through the blood-channels, and there lodged in a terminal 
bloodvessel, forming solitary tuberculous masses varying from the 
size of a pea to that of a hazelnut. These are surrounded by a 
zone of granulation-tissue. The neuroglia in the immediate vicinity 
is the seat of proliferation, and may form a capsule around the 
growth. Circumscribed meningitis over the situation of the growth, 
with adhesions of the pia mater to the dura, may be present. Fully 
half of these solitary growths occur in the cerebellum (Gerhardt). 
The growth may be single or there may be one large growth and 
several of smaller size. Starr and Seidl found a solitary growth in 
77 per cent, of the cases. The larger number of brain tumors in 
infancy and children are tuberculous. Starr found this variety in 
152 out of 300 cases of all kinds of tumors. 

The symptoms are those common to all tumors, and will be de- 
scribed in the section devoted to Brain Tumors. 

SYPHILIS. 

Acquired Syphilis of Infancy and Childhood. 

Etiology. — Of 42 cases of acquired syphilis collected by Four- 
nier, 19 were infected by the father or mother after birth, and cS 
by the nurse. X<> case was infected in passing through the ma- 
ternal parts, and no infant was infected by the mother if she had 



262 THE SPECIFIC INFECTIOUS DISEASES. 

contracted the disease just prior to her accouchement. A child of 
a syphilitic mother, if born free from signs of syphilis, cannot con- 
tract a primary lesion at birth from the maternal parts, even if 
these parts are the seat of condylomata, nor can such an infant be 
infected subsequent to birth. It has an acquired immunity against 
the disease. 

A chancre or primary lesion is, in the infant as in the adult, the 
only evidence of acquired syphilis. It is the result of infection, and 
must be present in order that the diagnosis may be certain. Chan- 
cres are rarely genital. They are found, as a rule, in the mouth, on 
the face, and on the abdomen and perineum. An infant may be in- 
fected by the nipple of the nurse's breast. The act of kissing, con- 
taminated nipples of the nursing-bottle, instruments, sponges, ritual 
circumcision, and humanized vaccine virus, are all means of infect- 
ing the infant. Since humanized vaccine virus is no longer used, 
this mode of infection has been eliminated. 

The symptoms consist of a chancre or initial lesion, rarely gen- 
ital, which appears three or four weeks after inoculation. The other 
accidents, such as bubo or adenopathies, the eruption, and all the 
secondary symptoms of acquired syphilis, appear in due course as in 
the adult. The genital chancre is seen in infections caused by ritual 
circumcision. 

The prognosis as to life is good in comparison with that in the 
hereditary form of the disease. While in the hereditary form the 
mortality is from 70 to 80 per cent., that in the acquired form is 
very low. Fournier lost only 1 in 42 cases of acquired syphilis. 
The course in infants and children is benign. The chancre is not 
well developed ; the induration is present only a short time, or may 
even escape notice. The infants enjoy good health in spite of the 
presence of the secondary symptoms. I have confirmed these state- 
ments by observing 7 cases of genital chancre. The tertiary mani- 
festations, such as gummata, bone lesions, joint-affections, eye and 
laryngeal symptoms, and cerebrospinal lesions, appear from five to 
twenty-five years after the initial lesion. 

Differential Diagnosis. — Acquired syphilis must be differenti- 
ated from the hereditary form of the disease. Hereditary or con- 
genital syphilis appears early without an initial lesion, showing gen- 
eral secondary symptoms from four to six weeks after birth. The 
chancre is the first manifestation in acquired syphilis. In Fournier's 
42 cases the chancre appeared during the first year of life in 19, and 
during the second year in 10 cases. The snuffles, pemphigus, and 
pseudoparalysis are not present in acquired syphilis. Secondary 
accidents, such as mucous patches or papules about the genitals, 
appearing during later childhood are probably traceable to a post- 
natal infection. Interstitial keratitis, bone syphilis, and cutaneous 
stigmata are common to the hereditary and acquired forms of the 



LATE HEREDITARY SYPHILIS. 263 

disease. It is sometimes very difficult to deeide which form of the 
disease is present. Thus far no one has shown conclusively that 
Hutchinson's teeth are present in acquired forms of syphilis in 
infancy and childhood. Their presence is therefore strong presump- 
tive evidence of hereditary syphilis. 

Late Hereditary Syphilis. 

(Syphilis Hereditaria Tarda.) 

Founder defines late hereditary syphilis as a symptom-complex 
of accidents of syphilis originating in a hereditary infection, which 
manifest themselves at a more or less advanced period of life, that 
is to say, in the majority of eases between the third aud the twenty- 
eighth year. There are two classes of cases. In the first, the 
patient has remained in perfect health without any of the eruptive 
or other symptoms of hereditary syphilis until at an advanced period 
of childhood one or more of the symptoms of late hereditary syphilis 
are developed. In the second, the late symptoms have been pre- 
ceded by the early symptoms of hereditary syphilis. The late symp- 
toms may develop after an interval of from ten to fifteen years. The 
cases of the former class have been the subject of much discussion. 
The occurrence of the second class of cases is now well established ; 
it is often very difficult to determine the hereditary or acquired 
nature of the original infection. 

Fournier, in classifying the symptoms of 212 cases of late heredi- 
tary syphilis, found the eye to be the organ most frequently affected. 
Xext in order of frequency are the lesions of the bones and skin. 
The rarer affections are those of the kidney, larynx, spinal cord, 
testes, and lungs. 

The subjects of late hereditary syphilis have certain well-defined 
general characteristics. They are constitutionally delicate and have 
an emaciated habitus. The skin presents a grayish anaemia. There 
is an arrest in the development of bone and musculature. The men 
are undersized and present the picture which has been characterized 
as infantilism. The signs of virility, such as the beard, hair under 
the arm and on the pubes, are scantily developed. The testes are 
rudimentary. The adult has the appearance of a boy of fourteen or 
fifteen years. The women are correspondingly backward in develop- 
ment. 

The Eye. — The eye symptoms appear most frequently at the age 
of ten or fifteen years, but may become evident as early as the third 
year. The principal symptom is a keratitis of the diffuse intersti- 
tial variety, the so-called keratitis of Hutchinson. The cornea has 
a slightly cloudy or filmy appearance, or the whole structure is dif- 
fusely opaque. The other ocular accidents are plastic iritis, which 
fixes the iris, thus limiting its action and causing a difference in the 



2<)4 



THE SPECIFIC INFECTIOUS DISEASES. 



size of the pupils. The rarest manifestations are miliary gummata 
of the iris. 

The bone-lesions are most frequent between the fifth and the 
twelfth year. 

The head presents a cuboidal shape ; the forehead is prominent ; 
the frontal bones have large bosses, as have also the parietal bones. 
The longitudinal suture is depressed, giving a natiform shape to the 
head. The cranium may have the form seen in mild degrees of 
hydrocephalus. 

The nose, on account of the destruction of the bony septum, has 
a depressed bridge. The bony and cartilaginous septa form an acute 



Fig. 74. 




Late hereditary syphilis ; bone deformity and sinus. Child, three years of age. 

angle, and a peculiar retrousse appearance is given to the organ. 
Both bony and cartilaginous septa may be destroyed. The whole 
organ is flattened, the tip of the nose being wrinkled into three or 
more folds. 

The long bones are especially affected by the accidents of late 
hereditary syphilis, the tibia being most frequently affected. The 
lesion may consist in an osteoperiostitis, a gummatous osteoperiostitis, 
or a gummatous osteomyelitis. 

If osteoperiostitis is present, there are diffuse swelling and thicken- 
ing of the bone — the so-called sabre-like deformity (Fig. 74). This 
process may affect the long bones of the upper extremities. The gum- 



CONGENITAL OR HEREDITARY SYPHILIS. 265 

matous lesions of osteoperiostitis form numerous irregular painful 
swellings on the bone. Gummata are present on the flat bones of the 
cranium. When these break clown, the destructive processes may 
expose the dura mater. Arthropathies with synovitis may be mis- 
taken for tuberculosis of the joint. This form of synovitis is gen- 
erallv bilateral. One of my cases, a child five years of age, gave 
no history of syphilis. The radius on both sides was affected by 
osteoperiostitis. The joints may be deformed by osteophytic growths 
involving the epiphysis or head of the bone. 

The ear is affected by an otitis with destruction of the ossicles, 
and even by mastoid disease. In other cases deafness supervenes 
without premonitory symptoms. 

The skin and mucous membranes show certain stigmata in the form 
of cicatrices of recent or old ulcerations. These may exist on any 
part of the body, but are especially characteristic on the vermilion 
border of the lips and at the corners of the mouth, where they are 
seen as radiating, linear pale-white fissures. 

The lymph-nodes may be enlarged, especially those on each side 
of the neck, below the jaw, and in the axilla and inguinal regions. 

The spleen is enlarged, but not so frequently as is stated by some 
authors. Fournier found it enlarged in 15 out of 212 cases. 

The liver was enlarged in 25 cases. In one of my cases of late 
hereditary syphilis in a child eight years of age, post-mortem exam- 
ination revealed cirrhosis of the liver of the hypertrophic type. 
There were enlargement of the spleen, icterus, and ascites ; Hutchin- 
son's teeth were well marked, and there were also adenopathies and 
vasculitis. 

Fournier among others has described forms of idiocy and epilepsy 
of syphilitic origin, but there is great difference of opinion on this 
question. The theory of Parrot, that rachitis is the result of syphilis, 
is now generally abandoned. The deformities of the teeth which 
occur in late hereditary syphilis will be found fully described in the 
section devoted to Dentition. 

Congenital or Hereditary Syphilis. 

Congenital or hereditary syphilis results from the infection of the 
ovule or foetus in utero. This may occur in a number of ways, 
but in the great majority of instances it results from infection of the 
foetus through the father. The more recent the syphilis of the 
father, the more likely is the infection to occur. It is most certain 
to occur if both the father and mother suffer from recent syphilis at 
the time of conception. The father may at the time of insemination 
suffer from recent syphilis and the mother be healthy. Under such 
conditions the child i< born syphilitic. The mother may not show 
any Bigna f) f active syphilis either during pregnancy or at any subse- 



266 THE SPECIFIC INFECTIOUS DISEASES. 

quent period. The mother may suckle her offspring, which shows 
all the marks of active hereditary syphilis, without becoming infected, 
but the child will infect any strange nurse. The mother has during 
pregnancy acquired an immunity against the infection. This phe- 
nomenon, which is a matter of daily observation, was first brought to 
the notice of the profession by the distinguished surgeon Colles, and 
has since become known as Colles's law. The longer the mother is 
subjected to the influence of the syphilitic virus, the more perma- 
nent does her immunity become. Thus a mother who has at first 
miscarried may eventually give birth to a living infant which bears 
the marks of syphilis. As the virus becomes weakened, the mother 
may bear an infant to all appearances healthy. In the interval, 
although repeatedly pregnant, the mother has shown no signs of 
active syphilis. 

If the father is healthy at the time of insemination and the 
mother the subject of recent syphilis, the infant will be born syphi- 
litic. On the other hand, if the mother contracts syphilis after 
conception, the father at the time of conception having been healthy, 
the infant may or may not be born syphilitic. The nearer the time 
of the infection of the mother to the end of her period of pregnancy, 
the more likely is the infant to escape (Monti, Zeissel, Hutchinson). 
Such an infant if born healthy may become infected in the ordinary 
way from the mother after birth. 

A father who has passed through the secondary manifestations of 
syphilis may in the late secondary period or tertiary stage fail to 
convey the poison in the sperma. The result will be an infant free 
from syphilis (Fournier, Neuman). Yet so far-reaching is the influ- 
ence of the syphilitic dyscrasia that such an infant, although born 
healthy and at no time showing signs of syphilis, may present certain 
signs, such as peculiarities of bone formation (teeth) traceable to the 
syphilitic virus (parasyphilitic). 

Exceptions to Colles's law occur, as is to be expected. Fournier 
has recorded cases in which mothers apparently immune have devel- 
oped signs of secondary syphilis after the birth of the infant. Finger 
has met cases in which tertiary syphilis developed in the mother sub- 
sequent to pregnancy without the occurrence in her of any of the 
signs of secondary syphilis. 

Of 218 mothers who had borne syphilitic infants, Hochsinger 
found 72 who were free from manifestations of secondary or tertiary 
syphilis although observed for years. 

Morbid Anatomy. — In considering the pathology of hereditary 
syphilis, Hochsinger divides the cases into four classes : 

The first class of cases die in utero before the eighth month, 
Autopsies upon such foetuses show general parenchymatous involve- 
ment of the glandular apparatus with epiphyseal osteochondritis. 

The second class includes infants born living or dead before the 



CONGENITAL OR HEREDITARY SYPHILIS. 267 

end of pregnancy. They present at birth a papulobullous syphilide. 
In these cases diffuse parenchymatous changes are found in the viscera, 
and frequently marked epiphysitis. 

The third class comprises infants born living and without any 
exanthema, but which later develop an exanthema independently of 
visceral or bony changes. 

The fourth class comprises infants born without an exanthema, 
but having at birth marked visceral and bone-changes. 

Taking up in detail the lesions found in the various parts of the 
body, we find that the skin shows an increase in the thickness of the 
rete Malpighii, caused by swelling of the cells of the rete, serous 
infiltration of this layer, and an increase of the spaces between the 
cells of the rete. The horny layer of the skin is much thinned in 
comparison, although there is a constant throwing-off of the cells 
of this layer in lamellae. The epithelium of the sweat-glands is 
swollen and there is a small round-cell infiltration between the 
glands. There is a vasculitis of the small bloodvessels affecting 
the external coat chiefly. Pemphigus and bullae result from infiltra- 
tion of the rete and the lifting up and separation of the horny from 
the papillary layer by serum. 

The Lungs. — The changes in the lungs may be considered under 
two heads : 

First, the lungs of infants born dead or who have died soon after 
birth, are collapsed, devoid of air, hypersemic, and dark red in color. 
In rare cases the lungs may be diffusely whitish yellow in color, 
giving the appearance of the so-called pneumonia alba. The second 
class comprises infants that have breathed, and that show a gray or 
grayish-white discoloration of the lungs in places. There is residual 
air in the lungs, and they are denser and larger than is normal. 

Ziegler has shown that the changes in the lungs consist chiefly in 
an increase in the interalveolar connective tissue, the formation of 
new vessels, and vasculitis of the bloodvessels. In the majority of 
newly born infants the alveolar epithelium is but little affected. In 
pneumonia alba there is a proliferation of the alveolar epithelium, 
giving a peculiar appearance and color, hence the name. 

The Liver. — Changes in the liver are quite constant in hereditary 
syphilis. These may or may not be associated with enlargement of 
the organ. Out of 148 cases of congenital syphilis, Hochsinger 
found the liver enlarged in 46 ; in all but 2 the spleen also was en- 
larged ; in the severer cases the liver was markedly so. 

The pathological changes in the liver have been described by 
Hudelo, Hochsinger, and Heller. There may be simply diffuse, 
small round-cell infiltration of the interstitial connective tissue, with 
inflammatory changes in the smaller arteries. The liver in these 
cases is not enlarged. In the eases presenting an enlarged liver 
there is interacinons proliferation of connective tissue, beginning at 



268 THE SPECIFIC INFECTIOUS DISEASES. 

the periportal region and following the course of the bloodvessels. 
There is vasculitis, shown in a thickening of the adventitia of the 
bloodvessels. The parenchyma is degenerated. In other cases inter- 
acinous collections of small round cells are on gross sections of the 
liver seen as yellow pinhead-sized spots. These are called by Hoch- 
singer miliary gummata. Fully developed gummata of large size are 
very rare in the liver of infants affected with hereditary syphilis. 

The spleen is in some cases enlarged to ten times its normal size. 
Gummata, single or multiple, occur, but are rare. In hereditary 
syphilis not only is the parenchyma increased, but also the connective 
tissue of the spleen. 

Kidneys. — In rare cases there are induration and contraction of 
the kidney. The parenchyma is retarded in development by intra- 
uterine syphilis and the connective tissue increased. 

The pancreas may be enlarged and infiltrated, the parenchyma 
hard, and the interstitial connnective tissue increased. There may 
be condylomatous ulcerations on the tongue, pharynx, and tonsil. 

According to Hochsinger, the glandular apparatus of the gut 
may show a diffuse small-cell infiltration, Peyer's patches may be 
infiltrated, and the vessels may be the seat of a vasculitis. The 
lymph-nodes are, as a rule, little changed except in cases with late 
manifestations. The thymus gland in cases of hereditary syphilis 
has been found to be the seat of cystic degeneration (Eberle, 
Ribbert), caused by the dilated epithelial spaces of the foetal 
thymus. 

Bone-changes. — The bone-changes in hereditary syphilis occur 
principally at that part of the bone between the epiphysis and 
diaphysis in the lower end of the femur, tibia, and radius. In the 
milder forms of bone-change there is, according to Ziegler, little real 
inflammation. There are irregularity in the deposit of lime salts 
and the formation of marrow-spaces. In severe forms there is a 
true inflammatory process. In the vicinity of the joint-cartilage, 
grayish-red, yellowish-white, or yellowish-green foci of osteomyelitis 
are found. The irregular deposit of lime salts and the formation 
of marrow-spaces are evidenced by reddish -yellow projections of mar- 
row-spaces into the adjacent proliferated cartilage. These give the 
epiphyseal junction a more irregular and widened appearance than is 
normal. Sometimes separation of the epiphysis at the junction of 
the diaphysis occurs. The above changes are frequent, although not 
constant. In the later stages of syphilis in children there are, as in 
the adult, caries, necrosis, and gumma formations in the long and 
flat cranial bones. 

Symptoms. — The symptomatology of hereditary syphilis varies 
largely with the class of cases. In some cases the foetus is expelled 
dead, bearing the marks of fully developed syphilis in the shape of 
skin, bone, and visceral lesions. In others the infant is born living, 



PLATE XIV. 




Congenital Syphilis. Showing nasal deformity 
Newborn infant. 



CONGENITAL OR HEREDITARY SYPHILIS. 



260 



Fig. 75. 



but presents a few very characteristic signs of syphilis, such as the 
presence of bullae or pemphigus either on the palms or on the soles 
of the feet. The vesicles may be rilled with a purulent fluid. As 
a rule these infants are emaciated. In some cases the bridge of the 
nose is sharply depressed and forms a distinct angle with the carti- 
laginous septum (Plate XIV.). This intra-uterine deformity in the 
newborn infant has been studied by Epstein. Such infants suffer 
from a troublesome coryza and cannot breathe freely through the 
nose. They present enlargement of the liver and spleen, and there 
may be a few copper-colored discolorations on the skin of the fore- 
head and nose. The lips have a shiny, glossy appearance, and after 
a time may present distinct rhagades. Some days after birth there 
is a diffuse syphilitic eruption of papules or vesicopapules, with the 
so-called diffuse induration of the skin of the palms of the hand 
and soles of the feet, described by Hochsinger. Here and there 
discolored spots which were formerly mistaken for papules may be 
seen. The skin of the face may have a diffuse coppery color. 
Patches of discolored skin appear 
and become confluent, the coryza 
and rhagades along the lips and at 
the angle of the mouth become 
more marked, and the rhagades 
bleed easily. 

In another class of cases the 
infant is born well nourished and 
has a good color. Within from 
two to four weeks a general erup- 
tion of papules and vesicopapules 
appears. Some of the vesico- 
papules are purulent, and after 
bursting dry up, leaving the sur- 
face covered with crusts on a 
copper-colored base. In these 
cases the manifestations on the mu- 

enn< mpml>mnp« innlnrlino- mrv7i Hereditary syphilis : rhaghades and mucous 

eons memorano, including coryza patches of upper and lower ii P s. 

and rhagades, are also gradually 

developed (Fig. 75). If the above symptoms are marked, we 
may find enlargement of the liver and spleen. I have seen the 
most marked signs of hereditary syphilis of the skin without the 
slightest enlargement of the liver or spleen. As a rule the arms 
will present papules, which may ulcerate at the points of contact 
with adjacent surfaces of skin. The typical condyloma lata is not 
frequent in early hereditary syphilis. The nates have a coppery 
Bhining color, are cracked in place- and diffusely indurated (Hoeh- 
Binger's induration). The trunk may present few symptoms. The 
bicipital glands are enlarged if the syphilitic exanthema is fully 




270 



THE SPECIFIC INFECTIOUS DISEASES. 



developed. The thighs show brownish, copper-colored patches. 
These patches give the skin a marbled appearance, which differs 
from that of the so-called healthy marbled skin in that the discolored 
areas are surrounded by normally colored skin, while in ordinary 
marbled skin the opposite condition obtains. On exposed areas, 
such as the knees, nates, soles of the feet, and palms of the hands, 
the skin is diffusely indurated. 

In a detailed consideration of the lesions, those of the skin are 
the first to engage attention. The most common forms of eruption 
are the papular or the papulopustular form of syphilide. This may 
be combined with the macular form ; in fact, it is common to find 
in the same case all forms in various stages of development. 

Fig. 76. 




Congenital syphilis : circinate syphilide of the nose. 



The papules occur on the forehead, palmar surface of the hands 
and plantar surface of the feet, and on the nates (Fig. 76). They 
show a distinct induration of the skin, are raised above the surface, 
and have a glossy, copper-colored appearance. On the nates or in the 
groin the papules may ulcerate ; very rarely these form condylomata 
lata in the early periods of congenital syphilis. The condyloma 
is a feature of the later period of this disease. Macules develop 
within the first three months of life, and from the sixth to the tenth 
week are associated with seborrhea. Infants thus affected are born 
with a peculiar anaemia, in which the skin has a cadaveric hue. The 
macules appear on the forehead and face as copper-hued spots, which 
increase in number until the skin has a general marbled appearance 



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CONGENITAL OR HEREDITARY SYPHILIS. 271 

(roseola syphilitica). They then fade, leaving the surface covered 
with brownish-red areas. These persist around the alae nasi and 
the forehead for a long time, giving the face a peculiar dirty -yellow 
spotted appearance. 

The diffuse syphilitic infiltration of the skin has been studied by 
Hochsinger. It is not the forerunner or the sequence of any papular 
eruption. It appears in the third week in 50 per cent, of the cases, 
and reaches its height between the eighth and the tenth week. It 
first presents discolored areas on the palms and on the soles of the 
feet, on the nates, the calves of the legs, also on the cheeks and 
chin, where it forms rose-colored or copper-colored areas which 
coalesce. The soles and palms may appear diffusely red or bluish 
and glossy. The skiu is diffusely thickened on the palms and soles 
and desquamates in lamella?. At the junction of the mucous mem- 
branes and skin fissures result on account of the thickening of the 
skin. The lips appear anaemic as a result of the infiltration of the 
mucous membrane, and are fissured. There are rhagades at the 
alae nasi. The rhagades at the angles of the mouth are covered 
with a bluish- white pellicle, and the surrounding skin is copper- 
colored. There are swelling of the nasal mucous membrane and a 
thin, purulent discharge mixed with blood. The hair falls out on 
account of the infiltration of the scalp ; the scrotum is thickened and 
fissured from the same cause. 

The blood shows all stages of anaemia, from the mildest to the 
grave pseudoleukaemic anaemia of von Jaksch, which some authors 
trace to syphilitic influences. 

The bones are affected with an osteochondritis, already described. 
This may appear in the first few weeks or at a much later period. 
It manifests itself by pain in moving the joints. The infant cries 
when handled. The mother notices that one arm lies motionless at 
the side, and that every attempt to move it causes pain. Parrot 
described this condition as a pseudoparalysis. At the junction of 
the epiphysis and diaphysis at the lower end of the humerus or 
radius the bone may be swollen and painful. As a rule, the process 
affects the upper extremity on one side only, but in severe cases 
both the upper and lower extremities may be involved. In some 
- this symptom may be present without a skiu eruption. The 
other conditions which simulate it are septic osteomyelitis involving 
the joints, and severe congenital rachitis. I have known instances 
in which prolonged observation was necessary to clear up the case. 

A very characteristic but not common affection of the bones Is 
the so-called dactylitis syphilitica ( Fig. 77). This may appear aa early 
as the fourth week, and may be associated with swelling of theepiphv- 

of the lon<r bones. It consists of a fusiform swelling of the 
phalanges of one or more fingers. According to Taylor, this is 
primarily a gummatous infiltration of the skin, the periosteum, bone, 



272 



THE SPECIFIC INFECTIOUS DISEASES. 



and epiphyseal cartilage becoming involved. In another form the 
periosteum and the bone itself are the seat of the gummatous inflam- 
mation, the epiphysis and the joint becoming involved later in the 
process. In neglected cases, fistulas and destruction of the joint may 
result from necrosis of the epiphysis. The diagnosis of these forms 
of dactylitis from tuberculous spina ventosa is sometimes difficult, 
and often impossible without mercurial treatment. I have lately 
seen a case of rachitis which involved the phalanges of all the fingers, 
and which simulated very closely the above affection (see Rachitis). 
Syphilitic affection of the liver gives no symptoms. Henoch 
records cases in which icterus was associated with enlargement of 

Fig. 77. 




Congential syphilis : onychia of all the nails ; dactylitis of the phalanx of the index finger. 
Infant, four months of age. 

the organ. Hochsinger denies the occurrence during the nursing 
period of any authentic case of syphilis of the liver with icterus or 
ascites. 

Somma, Fischl, and Kohts have described symptoms of cerebral 
syphilis in infants that were subjects of hereditary syphilis. Con- 
vulsions, hydrocephalus, epilepsy, and paralyses have been traced to 
the presence of gummous meningitis or sclerosis. That such changes 
occur as a direct result of syphilis at so early a period is doubted by 
Henoch. I have not seen manifestations of cerebral syphilis in 
infants. Henoch is also inclined to include Mracek's cases of 



COSGESITAL OR HEREDITARY SYPHILIS. 



273 



hemorrhagic syphilis among the septic diseases of the newborn occur- 
ring in syphilitic infants. 

Antonelli in 1897 described changes in the fundus oculi of new- 
born syphilitic infants. These consisted of optic neuritis, retinitis 
vascularis, and retinochoroiditis. He believes these changes to be 
causative in the production of myopia and strabismus in such infants. 

The diagnosis of hereditary syphilis is not difficult in the vast 
majority of cases. If the foetus is expelled dead, it bears the marks 
of syphilitic infection, such as bulla? and affections of the inter- 



nal 



Maceration alone is not indicative of syphilis. If 



Fig. 78. 




Hereditary syphilis : gummata of the cranial bones. Child, eighteen months of age. 

the infant is born living, the evidences of syphilis are sometimes 
very few and equivocal. After a few months the diagnosis will 
sometimes be difficult ; the eruption will have disappeared, leaving 
only an anaemia of uncertain origin, with a few discolored areas 
about the nasolabial folds and around the temporal region. There 
is a suspicious dirty-looking seborrhcea of the supra-orbital region. 
A rebellious anal eczema or copper-colored intertrigo which resists 
treatment should arouse suspicion. Pustular papules are not pathog- 
nomonic even if combined with joint-affections. A case came under 
my notice in which an infant had a varicella-like eruption with a 
painful swelling of the right elbow-joint. A diagnosis of epiphy- 
sitis syphilitica had been made and the eruption had been mistaken 
for a syphilide. The color of the eruption was not that of a syphi- 
lid-. Expectant treatment and immobility of the joint proved, after 
a few days, that the case was one of varicella with the joint-compli- 
cation -ometimes seen in that disease. 

In the diagnosis of late hereditary syphilis the symptomatology 

18 



274 



THE SPECIFIC INFECTIOUS DISEASES. 



is of service. In cases with bone-lesions it is often very difficult to 
differentiate it from tuberculous affections (Fig. 79). An active course 
of treatment then becomes necessary, with a view to diagnosis. 
This is especially the case in arthropathies, and also in late forms 
of dactylitis. 

The prognosis as to life depends upon several factors. A breast- 
fed infant is more likely to survive than a bottle-fed infant. The 
possibility of complete restoration to the normal is slight. The 
majority of infants bear the marks of the disease into adult life, 
even under very favorable conditions of treatment and environment, 
and develop late in life the so-called late symptoms of hereditary 
syphilis. Some infants while progressing favorably under treatment, 
die suddenly without apparent cause; others remain stunted and 

Fig. 79. 




Tuberculous affection of the bones of the hand simulating syphilitic disease. Child, sixteen 

months of age. 

delicate throughout childhood. Rachitis and its sequelae seem to be 
very prevalent among infants that are the subjects of hereditary 
syphilis. 

The treatment of congenital syphilis may be either internal or 
by inunctions or injections. I have found internal treatment to be 
the more satisfactory. The effects of the mercury are not so injuri- 
ous as is the case with the inunction methods. The drug employed 
was calomel in combination with the saccharated ferric carbonate 
(this was a favorite remedy of Widerhofer) : 



Calomel . . . . 
Ferri carb. sacc. 
Ft. pulver. 



gr. * (0.01). 
gr. nj (0.18). 



A powder of this size may be given every three hours or four times 
a day. Some authors (Baginsky) prefer the protoiodide of mercury, 
grain \ to \ (0.01 to 0.03). If there is intolerance to calomel, 



CONGENITAL OR HEREDITARY SYPHILIS. 275 

satisfactory results may be obtained by the use of Lustgarten's 
preparation of hydrarg. oxydulatum tannicum, in doses of grains ij to 
v (0.1 to 0.3), repeated every three hours or four times daily. 

If the rhagades, especially those about the anus, bleed or heal 
slowly, they should be stimulated with a weak solution of silver 
nitrate. Calomel should be dusted upou condylomata lata three 
times daily. 

Baths of sublimate are recommended in severe cases of pemphigus, 
but it is not often necessary to resort to them. 

Infants in the nursing period do not bear inunctions well. I 
have seen several cases treated by this method which lost weight 
rapidly or died suddenly, and this has been the experience of others 
(Monti). The old method Avas to place grains viij to xv (0.5 to 1.0) 
of unguentum hydrarg. under the flannel abdominal binder daily, 
and allow it to be absorbed, or the same quantity of ointment was 
rubbed in daily on various parts of the body. 

Severe rhinitis is best treated by washing out the nasal passages 
once a day with a solution of corrosive sublimate (1 : 2000). The 
small glass syringe with a blunt soft-rubber nozzle is best for this 
purpose. After the syringing, unguentum iodoform, is applied to 
the interior of the nose by means of a camel's hair pencil. 

How long should treatment be continued? Xo matter what 
method of treatment is adopted, mercury should be administered 
until all discoloration of the skin has disappeared. To attain this 
result will take a varying length of time in different cases. After 
the skin is clear and the anaemia has disappeared, it is well to cease 
the administration of drugs and observe the patient for further symp- 
toms. Sometimes a patient will be brought to the physician for the 
treatment of a rebellious intertrigo long after all signs of general 
syphilis have disappeared. Such an intertrigo may have a copper 
color, and may ulcerate, the ulcers having a peculiar lardaceous 
appearance. In these cases, even if all other signs of congenital 
syphilis are absent, the internal administration of mercury gives 
brilliant results. 

The treatment of late hereditary syphilis will depend much upon 
the nature of the therapeutic measures adopted earlier in life. In 
the majority of cases, the subjects being in later childhood or ado- 
lescence, it is well to begin treatment by a full inunction course, 
conducted on the same plan as with adult subjects with acquired 
syphilis. In addition, if gummatous affections of the bones are 
present, and if as in one of my cases visceral lesions, such as enlarge- 
ment of the liver, have appeared, the patient is put upon gradually 
increasing doses of iodide of potassium. In one of my cases large 
doses of iodide of potassium foiled t<> relieve the intense headache. 
Tlii< patient married, and after having a miscarriage gave birth 
under specific treatment to a healthy infant. The treatment of 



276 THE SPECIFIC INFECTIOUS DISEASES. 

acquired syphilis does not differ from that of congenital or late 
hereditary syphilis. 

Leading Authorities Referred to in Chapter III. 

Anton W.: Die diphtherie der nase, Jena, 1897. 

BaqiTisky, A.: "Diphtherie," etc., NothnagePs Spec. Path. u. Therap., 1898, Bd. 
ii., I. Theil. 

Behring, E. : Therapy of Infectious Diseases, Parts I. and II., Berlin, 1900 
(allgm. therapie der infec. Krankheit). 

Blackader, A. D. : " Kelation between Human and Bovine Tuberculosis," Bos- 
ton Medical Journal, Dec, 1901. 

Blumer,G.: "Infection in Infants due to the Typhoid Bacilli," Trans. Amer. 
Med. Assoc, 1900. 

Celli, A. : Malaria, Vienna, 1900. Beitrg. zur exper. Therapie. 

Cornet, G. : " Die Scrofulose," Nothnagel's Spec Pathol., Bd. xiv. 

Councilman, Mallory and Pearce: Bacteriology and Pathology of Diphtheria, 
Sears Lab. Kep., 1901. 

Councilman, Mallory and Wright : Keport State Board of Health of Massachusetts, 
1898. 

Dennig, A. : Tuberculose im Kindesalter, 1896. 

Duel, A. R. : "Acute Otitis Media and Mastoiditis in Scarlet Fever and Measles 
and Diphtheria," Keview of Reviews, 1901. 

Fielder, F. S. : " Vaccination," Medical News, 1901. 

Fournier, A.: Syphilis hereditaire tardive, Paris, 1886. 

Gaesler : Mittelorrhe bei Scarlatina, 1900. 

Gershel, M. : "Value of Widal Reaction," etc., Med. Rec, Nov., 1901. 

Herzfeld : "Tubercul. Peritonitis," mittheilungen aus dem grenzgebiet der med., 
1901. 

Hochsinger, C. : Hereditare Syphilis, Vienna, 1898. 

Koplik: "Cerebrospinal Meningitis," Medical News, 1901. 

Koplik: " Malaria in Infants and Children," New York Medical Journal, 1893. 

Koplik: " Measles Spots," Archives of Pediatrics, 1896. 

Macewen: Pyogenic Diseases of the Cord, 1893. 

Mattie, L. : Serotherapie preventive de la diph., 1901. 

Morse, J. L. : " Widal Reaction," Archives of Pediatrics, 1901. 

Nelter : "Meningitis," Transactions International Medical Congress, 1900. 

Nobling-Jankau : R. Fischl in Prophvlaxis der Krankheiten des Kindesalter, 
1900. 

Pearce, R. M. : "Scarlet Fever," Medical and Surgical Reports, Boston City 
Hospital, 1899. 

Pearce, B. M. : " Bac access sinuses scarl. and diph.," Journal Boston Society 
Medical Sciences, 1899. 

Benaud: These, Leucocvtosis in Measles, Paris, 1900. 

Schmidt: " Rotheln," etc., Wien. klin. Wochenschr., 1900. 

Shaw, H. L. K. : "Prophylaxis Antitoxin," Albany Medical Annals, 1901. 

Slawyk: " Koplik's Spots," Deutsche med. Wochenschr., 1898. 

Thursfield, H. : " Posterior Basic Meningitis," Lancet, 1901. 

Wentworth : " Meningitis in Infants and Children," Boston Medical and Surgical 
Journal, 1898. 

West, J. P. : "Glandular Fever, with Literature," Archives of Pediatrics, 1896. 



CHAPTER IV. 

DISEASES OF THE MOUTH, PHARYNX, AND LARYNX. 

THE CHARACTERISTICS OF THE NORMAL MOUTH. 

There are certain localities in the mouth which are particu- 
larly liable to aphthaB and ulceration. The mucous membrane over 
the hamular processes of the palate bone presents whitish areas 
paler than the surrounding mucous membrane. These areas may 
be the seat of the so-called Bednar's aphthae. Midway in the 
raphe of the hard palate in the majority of newborn infants 
are seen one or two, at most three, yellowish-white, sago-like 
bodies. They are called Epstein pearls, and were first described by 
Epstein as collections of epithelial cells, the remains of embryonal 
life. They may be easily injured, and then become the seat of 
ulceration. 

At the side of the hard palate over the alveolar process, above 
and below, the mucous membrane is thin and white in reflex. A 
slight traumatism may cause ulceration in this region. The tonsils 
of the newly born infant are hardly visible. The posterior pharyn- 
geal wall has a glossy, smooth, bluish-pink reflex. 

On close examination of the anterior pillars of the fauces of 
infants, bodies resembling drops of dew or vesicles are seen just in 
front of the location of the tonsil. These are collections of lymphoid 
tissue and are normal in the infant's mouth. They sometimes become 
inflamed and form aphthous ulcerations, and are then called herpes 
of the tonsil. There are also visible on the soft palate of children 
minute, miliary, transparent bodies having the appearance of vesicles. 
These are present in the normal state, and are likely to enlarge in 
diseases affecting the throat or in the exanthemata. They are aggre- 
gations of lymphoid tissue. 

DENTITION. 

The eruption of the temporary or milk-teeth begins about the 
sixth or seventh month, with the lower incisors, and ends about the 
third year, with the posterior molars. The eruption of the teeth, 
even in normal infants, varies within wide limits. The following 
table includes the most important facts concerning the normal erup- 
tion of the milk-teeth : 

277 



278 DFSEASES OF THE MOUTH. 

rp , . . / 6th-10th month. 

Two lower incisors . { Average 7th month. 

Two upper lateral incisors lOth-ltith month. 

Two lower lateral incisors 12th-16th " 

Four anterior molars 14th-21st " 

Four canines . 16th-25th " 

Two upper incisors 9th-10th-16th month. 

Four posterior molars 18th-36th month. 

The second dentition begins in the seventh year, with the erup- 
tion of the first molar behind the second temporary molar. The 
central incisors appear about the eighth year ; the lateral incisors, 
at the ninth year ; and the last molars, from the eighteenth to the 
twentieth year, or later. 

At the twelfth month a baby should have the upper and lower 
central incisors, with the two upper lateral incisors coming. The 
lower incisors may not appear until the eighth or ninth month, and 
may then be followed rapidly by others. I have seen several infants 
with one or two incisors at birth. These were imperfectly formed 
and resembled canines. As a rule prematurely erupted teeth should 
be extracted, as they lacerate the nipple in nursing. I have seen 
rachitic, bottle-fed infants who did not cut their first tooth until the 
twenty-fourth month. 

Rachitis is a common cause of delayed dentition. Artificially 
fed infants are backward in cutting their first incisors. It is 
common to see bottle-fed infants cutting the lower anterior incisors 
at the ninth month. The infants may be in other respects normal. 
Rachitis affects the teeth of the first dentition mostly, but may influence 
the form and structure of the teeth of the second dentition. The 
teeth of the first dentition in rachitis are easily broken and are 
unnaturally white. In many cases the anterior incisors show an 
incurvation on the lower cutting edge, which is often mistaken by 
the inexperienced for Hutchinson's deformity. The first teeth in 
rachitis are easily eroded. It is not uncommon to see a rachitic 
infant with its whole dental system in process of decay. The per- 
manent teeth present abnormalities in inordinate size and longitudinal 
furrows. 

Syphilis. — The permanent teeth are affected by syphilis in a 
characteristic fashion. 

Hutchinson's teeth are so called because they were first described 
by Jonathan Hutchinson. They are the only teeth of the per- 
manent set which are pathognomonic of congenital or very early 
acquired syphilis (infancy) (Fig. 80). In a large experience with 
syphilis in infancy and childhood I have seen but few perfect examples 
of these teeth. The teeth presenting the deformity are the central upper 
incisors of the permanent set, and these only. " These teeth show 
a central single, rather broad notch." In this notch the dentine, 
lightly covered by enamel, is exposed. It is seen as a ridge in the 



DENTITION. 



279 



incurvation. The teeth are shorter and broader than is natural, 
and almost always have their angles sloped off. They are thus 
narrower at their cutting edge than higher up. They are seldom 
or never of good color, and frequently are not placed quite straight, 

Fig. 80. 




Hutchinson's teeth in a boy, twelve years of age. 

but slope either toward or away from each other. Teeth which 
are the seat of erosion may resemble Hutchinson's teeth (Fig. 81). 
Fournier has described teeth in the temporary set which closely 



Fig. 81. 




^tfA-r-y- 



Permanent teeth deformed through stomatitis in early childhood, resembling Hutchinson's 
teeth. Female child, nine years of age. 

resembled Hutchinson's teeth. I have met an exquisite example 
of such teeth in an infant sixteen months old, the subject of 
syphilis (Fig. 82). 

In syphilitic subjects we find the following deformities in the 



280 



DISEASES OE THE MOUTH. 



permanent teeth. 



Fig. 82. 



/a./: 




These peculiarities are not characteristic of 
syphilis alone, but are found in those who 
are not syphilitic, but have suffered from 
stomatitis or dyscrasia of some kind. The 
changes are bilateral and symmetrical. 

Dental Erosions. — The most important 
erosions, such as those of Hutchinson just 
described, affect the central incisors. Other 
erosions give the teeth an incurvated ap- 
pearance on their cutting edge. In this 
incurvation is seen a supernumerary crown 
ribbed in a longitudinal direction (Figs. 83 and 84). The whole 
may be mistaken for Hutchinson's deformity. They result from 
malnutrition or stomatitis with faulty formation of dentine and 
enamel deposit in the eruptive period of the permanent teeth. The 
first molars show very characteristic deformities, which Fournier 



Central upper incisors of 
the first dentition resembling 
Hutchinson's teeth. Syphilis 
of the flat and long bones. 
Child, sixteen months of age. 



Fig. 83. 




Fig. 84. 






P!ig3| 

|ft# 



Upper central incisors, with erosions not 

syphilitic. Lower incisors, with erosions not syphilitic. 

* Child, eight years of age. 

places next in importance to those of the Hutchinson teeth, but 
does not regard as pathognomonic of syphilis, although they are 
met in syphilitic subjects. This deformity of the first molars is 
shown in Fig. 85, taken from a child who showed other erosions, 
but gave no history of syphilis. I have seen these erosions very 
well marked in children who had positive syphilitic manifestations. 
The top of the crown is constricted, and there appears to be a 
double crown. Erosions are also seen in the canine teeth. 

Microdontism. — The teeth are quite small, but if cared for remain 
perfect in shape, pearly and transparent. They are seen in children 
whose parents may have suffered from syphilis. The children may 
also have obstinate eczema of the anus (parasyphilitic). Micro- 
dontism may occur also as a result of any non-syphilitic dyscrasia. 

Dental infantalism, described by Fournier, occurs in children 
who are syphilitic. Small teeth presenting erosions are interspersed 
among teeth which are normal in size and shape. 



PATHOLOGY OF DESTITIOX. 



281 



Amorphism, or the tendency of a tooth, such as the incisor, to 
take the shape of a canine, has been noted by Fournier. I have 
also met with eases of this deformity in congenitally syphilitic chil- 
dren. It is seen in children who have had syphilis, but may be 
met with in those who have no such history. 

Children, subjects of syphilis, do not always present deformi- 
ties of the teeth. In a girl of fourteen years, who gave a history of 
infantile syphilis, and who had late manifestations, such as gummata 



Fig. 85. 



Fig. 86. 




Erosion of molars, not nec- 
essarily syphilitic. 




Molar tooth, showing erosion at 
crown. Boy, twelve years of age; 
same patient as with Hutchinson's 
teeth. 



in almost all the bones, joint-affections, and gummata of the liver, 
the teeth, both upper and lower, were normal, of great beauty, and 
well preserved. 

Pathology of Dentition. 

The period of infantile dentition is one of great physiological 
activity and growth. The organism is forming at this time. 
The nervous system is in a condition of instability. The gut is 
exposed to all varieties of infection, and is very susceptible to 
them. During this period the infant or child suffers from a number 
of diseases and exhibits a variety of symptoms which in former times 
were difficult of interpretation. AVith advancing knowledge and the 
possibility of making more accurate diagnoses than were formerlv 
feasible, the diseases incidental to dentition have become more a 
matter of speculation. There are clinicians of note who still believe 
that irritation of the trigeminal branches by an erupting tooth may 
cause reflex eclampsia. It is difficult, and not necessary, to pass 
here on the statu- of that section of infantile pathology which 
treats of the disorders incident to dentition. In the presence of 
mystifying symptoms the physician should make a very careful 
examination, in order to make the diagnosis. Clinical observation 
of a case for a few days, and accurate registration of the pulse, 
respiration, and temperature every three hours, may show that the 
diagnosis of dentition must give way to something more tangible. 

Should the Gums be Incised? — I have often found the tooth- 
to be swollen and the -eat of painful distention just before the 
eruption of the teeth. In one case the tooth-sac was distended by a 



282 DISEASES OF THE MOUTH. 

hemorrhage into its cavity. Under these conditions I have never 
yielded to the entreaties of the mother to lance the gums. I have 
seen no ill effects result from this laissez /aire method. Very painful 
ulcerations result from friction, and uncontrollable hemorrhage may 
follow incision. In cases in which the sacs are distended, the func- 
tions of the stomach and gut should be kept normal, in order that 
complications may not be added to existing conditions. In rare 
cases I have seen suppuration in the tooth-sac, and have incised. 
In some cases of scurvy the tooth-sacs are distended and bluish 
in appearance. Treatment of the scurvy improves this condition. 



APHTHOUS STOMATITIS. 

(Stomatitis Aphthosa.) 

In this condition there are formed on the soft and the hard palate, 
the mucous membrane of the gums and tongue, and on the inner 
surface of the lips and cheeks, small round yellowish superficial 
ulcerations. These ulcerations, which vary in form and number, 
may coalesce and form irregular plaques. It is a question whether 
the ulcerations are the remains of vesicles which have burst, thus 
exposing an ulcerated base, or whether they are primarily ulcers. 
I am inclined to the former view, for in the so-called herpetic 
aphthae of the tonsils the natural development of the aphthous 
ulcerations can be observed to advance from the vesicular to the 
ulcerative stage. This condition is very common in infancy and 
childhood, and according to Monti is most frequent between the 
first and the third year. 

The etiology is still obscure. Some authors consider aphthous 
stomatitis an acute infection derived from the gut, possibly caused 
by toxins generated in contaminated milk (Forcheimer, Hitter, 
Kmeriem, Schamtyr). Others, basing their opinion on bacteriologi- 
cal studies, regard it as a purely local affection. The clinical course 
of the disease tends to support the former view. It has been com- 
pared by Forcheimer and others to the so-called foot-and-mouth 
disease of cattle. 

The condition may occur idiopathically or may complicate intes- 
tinal infection, the exanthemata, bronchitis, tonsillitis, and pneu- 
monia. Some authors believe that the affection may be communi- 
cated to others by the secretions of the mouth. 

Bacteriology. — The forms of bacteria most commonly found in 
the ulcerations are the various streptococci and staphylococci (Jadas- 
sohn). Bernabei has found the pneumobacillus of Friedlander. As 
these bacteria are present in the normal secretions of the mouth, it is 
doubtful whether they bear a causal relation to the condition. 

Symptoms. — These aphthae vary from the size of a pin's head to 



BEDNAR'S APHTHjE. 283 

that of a split pea. They are invariably surrounded by an areola 
of inflamed mucous membrane. The outline of the ulceration may 
be round or irregular ; as a rule the ulcerations are superficial. At 
the line of junction of the teeth and gums they may show a ten- 
dency to bleed if touched. There is considerable pain, with saliva- 
tion, and in young infants also a distinct febrile condition and green 
diarrhoeal movements. In other cases there may be an accompany- 
ing angina with swelling not only of the lymph-nodes at the angle 
of the jaw, but also of those underneath the jaw. In addition there 
are loss of appetite, and restlessness at night. 

Course. — In well-nourished infants and children the tendency is 
to limitation of the aphthae and spontaneous recovery within three or 
four days. In marantic or badly nourished children in unhygienic 
surroundings, the aphthae are likely to spread, the ulcerations pre- 
senting the appearance of a mixed infection. Such cases are difficult 
to control. As a rule, however, the disease runs its course without 
leaving any lasting ill results. 

The treatment of the cases in which the ulcerations or aphthae 
remain discrete and in which mixed infection does not occur is 
begun with a saline cathartic, such as magnesia, or a dose of calomel. 
The mouth should not be washed. Careless attempts to cleanse the 
mouth are likely to cause the aphthae to coalesce and spread, and 
also to cause intense pain. I administer a small dose of ferric 
chloride, made up with glycerin, every three hours. In most cases 
this will suffice. The use of potassium chlorate should be avoided 
with infants. If the edges of the gums adjacent to the teeth are 
affected, the teeth should be gently washed three times daily with a 
weak solution of tincture of myrrh or a saturated solution of 
boric acid. If the aphthae coalesce, they should be touched once 
daily with a 2 per cent, solution of silver nitrate. With intractable 
young children, care should be taken in washing the mouth not to 
traumatize the unaffected mucous membrane. 



Bednar's Aphthae. 

Bednar's aphthae, named after the distinguished Viennese pedi- 
atrist who first described them, are two symmetrical ulcerations over 
the hamular process of the palate bone, seen in the newly born or 
very young infant (Fig. 87). In a large number of cases they are 
the result of traumatism. The finger of the nurse impinges on the 
processes of the palate bone when it is introduced into the mouth, 
and abrades the epithelium. Any bacteria which may be present in 
the mouth or on the finger thus gain foothold and ulceration results. 
Epstein ha- shown that in the newly born infant such ulcers may be 
the starting-point of a general Bepsis. 



284 



DISEASES OF THE MOUTH. 



The infant may refuse to nurse, or if it does attempt to do so, 
the pain caused by the act of suckling causes it to desist. There may 
be intestinal disturbance, manifested by greenish stools and caused 
by infection of the gut by the bacterial flora of the ulcerations. 



Fig. 87. 




View of hard and soft palate. Lateral ulcerations— so-called Bednar's aphthae. The central 
dark spots in the raphse are Epstein's pearls. 

Treatment. — The ulcer should neither be washed nor trauma- 
tized. The rest of the mouth and tongue should be washed gently 
twice daily with a saturated aqueous solution of boric acid. The 
ulcers should be touched once or twice a day with a 10 per cent, 
solution of silver nitrate applied with a small piece of cotton on an 
applicator. 

SPRUE. 

(Thrush; Muguet (Fr.) ; Soor (Ger.).) 

Sprue is a parasitic growth on the mucous membrane of the 
buccal cavity of the newborn or very young infant. It may spread 
to the nose in cases of cleft palate ; in other cases it may spread to 
the pharynx, larynx, oesophagus (Parrot), and even to the stomach 
(Parrot, Henoch, Northrup). The latter situation is not favorable 
to its growth. The parasite has been found in the movements of 
infants suffering from the disease. 

Nature. — Sprue is one of the mould fungi. Its classification by 
various authors varies with the species examined. Older authors 
classed sprue with the oidium as Oi'dium albicans. Rees, Grawitz, 
and Kehrer classified it as a Mycoderma albicans, consisting of 
conidia and mycelia. Plaut classifies it as a common mould fungus 
(Monilia Candida). 



SPBUE. 285 

In the early stages it presents large or small irregular whitish 
masses. These may at first be very minute, covering only the sum- 
mits of the papillae of the tongue. On the buccal mucous mem- 
brane they may be as large as a pin's head or coalesce into masses 
resembling curdled milk. They may be seen on the roof of the 
mouth, on the soft palate, tonsils, and posterior pharyngeal Avail. 
If the affection is progressive, the tongue and inner surface of the 
cheeks become coated with a white closely adherent pellicle. In 
neglected cases the sprue may be of a yellowish color if sarcinse are 
present, or blackish or grayish in hue if other fungi have obtained 
lodgement. Considerable force is requried to dislodge the growth 
from the mucous membrane, and the operation will cause bleeding 
and considerable pain and traumatism. 

Occurrence. — The organism is introduced into the mouth from 
without. It is present in the vaginal secretions of the mother, and 
has been found on the breast nipple. An abrasion of the mucous 
membrane must exist in order that the fungus may obtain lodge- 
ment. It is therefore found in infants whose mouths have been 
harshly washed with unclean fingers or into whose mouths unclean 
breast or bottle nipples have been introduced after harsh washing. 
The fungus having gained access to the cement-substance between 
the epithelial cells, proliferates into the deeper layers of epithelium, 
and may even invade the underlying connective tissue. Sprue carries 
with it any other bacterial flora which may be present in the mouth. 
A perfectly normal mucous membrane is not vulnerable to sprue. 
The sprue conidia and mycelia are found in the secretions of the 
mouth of the normal baby. Sprue is seen chiefly in infants whose 
health is below the average, who are inmates of institutions, or who 
have been in uiihvgienic surroundings. 

Symptoms. — The local symptoms are due to the presence of the 
growth. In mild cases the patches are few in number and very 
minute. In neglected cases not only is the whole mouth the seat of 
the disease, but also evidences of infections of a pyogenic nature 
occur in the form of erosions of the buccal mucous membrane, 
yellowish plaque-like ulcerations and fissures which bleed easily. 
There is also dryness of the mucous membrane which has not been 
attacked or which has been freed from the fungus. Sprue, in 
fact, causes distinct reaction of the healthy mucous membrane in 
the vicinity of its invasion. Infants, even in the early stages, suffer 
from mild disturbances of the gastro-enteric tract, manifested by 
vomiting and greenish movements. In neglected cases marantic 
symptoms are also present. Older writers (Parrot) believed sprue 
to be a causal factor in athrepsia. It is simply regarded as a 
complication. 

That pain is felt is evinced by the lack of desire to nurse the 



286 DISEASES OF THE MOUTH. 

breast. A febrile movement occurs if the intestinal tract is in- 
volved. 

Treatment. — Prophylactic. — Everything that is introduced into 
the mouth of the infant should be scrupulously clean. If the infant 
is breast-fed, the breast nipple should be cleansed before and after 
nursing with a pledget of cotton moistened with boric acid. The 
infant's mouth should not be cleansed after nursing. In cases in 
which the roof of the mouth has been carelessly cleansed there are 
not only the aphthae of Bednar, but also sprue and other aphthae in 
the median line as a result of traumatism to Epstein's pearls. If 
infants are fed artificially, the nipple of the nursing-bottle should 
be boiled in soda solution once. (See page 46.) If these pre- 
cautions are carefully observed, and unclean fingers never intro- 
duced into the infant's mouth, sprue will rarely if ever occur. The 
normal epithelium and normal secretions are safeguards against the 
fungus. 

Curative. — The growth should be removed by cleansing the 
mouth gently three times a day with a saturated solution of boric 
acid. The utmost gentleness should be used. Even in mild cases 
the removal of the sprue may extend over a number of days, 
because the parasite quickly reproduces itself. I use one piece of 
absorbent cotton for the roof of the mouth, another for the tongue, 
and another for the cheeks and lips. If it can be avoided, the 
mucous membrane should not be caused to bleed. If aphthae exist, 
they should be touched lightly with a 2 per cent, solution of silver 
nitrate. The bowels should be opened by an initiative mild cathartic. 
Everything should be scrupulously clean. The severe cases, iu 
which there is a septic condition due to extension of the sprue to 
the gastro-enteric tract, occur chiefly in foundling asylums. The 
infants die of septic infections. In private practice the prognosis 
is good if the case is seen early and correctly treated. Baginsky 
recommends potassium permanganate (1 : 150) ; others recommend 
corrosive sublimate (1 : 2000), but boric acid will be found to be 
equally satisfactory. 

Henoch describes cases of sprue of the stomach. This is admit- 
tedly rare, and occurs in the form of slightly prominent plaques. 
Parrot describes sprue of the gastric mucous membrane as not infre- 
quent. 

TOXIC STOMATITIS. 

I have seen a number of cases of stomatitis caused by irritant 
poisons, such as potash and ammonia. The children so affected had 
attempted to drink a solution of potash or ammonia from a bottle 
left within their reach. 

The symptoms were purely local. The mucous membraues of 



ULCERATIVE STOMATITIS. 287 

the lips had a characteristic (Edematous, swollen, and transparent 
appearance, the buccal mucous membrane and the tongue were pale 
and (edematous, and the papillae were erect and transparent. 

The treatment was expectant. A mixture containing bismuth 
subcarbonate seemed to give most relief. On subsidence of the 
oedema the mucous membrane presented a dry appearance. Some- 
times small aphthous ulcerations appeared, which healed under ap- 
plications of a 2 per cent, solution of silver nitrate. 

In one case, five years of age, symptoms of oesophageal stricture 
were present three months after the ingestion of the irritant. Strict- 
ures of the oesophagus are more common after the ingestion of potash 
or lye solutions than after corrosion by ammonia. 



ULCERATIVE STOMATITIS. 

(Stomatitis ulcerosa; Stomacacw ; Ger., Mundfaule.) 

Ulcerative stomatitis is a disease of the mucous membrane of the 
mouth, gums, and tongue, which is characterized by ulceration with 
a fetid odor. 

The etiology is still obscure. Friihwakl and Bernheim found 
bacilli and spirochaetse (spirilla) in the ulcers. The fetid odor of 
the breath was reproduced in the cultures of Bernheim. The bacillus 
is lanceolate in form and resembles the diphtheria bacillus. These 
bacilli and spirilla are probably identical with those described in 
1896 by Vincent as occurring in hospital gangrene. 

The affection is most common between the fourth and the eighth 
year. The period of infancy seems to be exempt, in my opinion 
because of the absence of teeth. It occurs in children who have 
been neglected or who have lived in unhygienic surroundings, and is 
therefore very common in clinics and dispensaries. In the milder 
forms there is a line of yellowish ulceration along the margin of the 
gums at the point of contact with the teeth, and the adjacent mucous 
membrane is red and inflamed. When the gums are touched either 
in washing or in examination, bleeding occurs. There is a fetid 
odor of the breath, the tongue is coated ; some children have pain 
and loss of appetite, and a slight febrile reaction. In the severer 
cases there are deep ulcerations along the margins of the gums, 
which bleed on the slightest provocation. Ulcers with a greenish- 
yellowish base are seen along the border of the tongue and beneath 
it. In these cases the lymph-nodes beneath the body of the jaw are 
enlarged and painful as a result of the infection. The salivation, 
pain, and local disturbance are considerable, and the fetor is marked. 
The buccal mucous membrane at the points of contact with the 
teeth may be deeply ulcerated, indurations of the tissues of the 
adjacent mucous membrane being also present. Small particles of 



288 DISEASES OF THE MOUTH 

necrotic tissue are seen to flow away in the saliva. So great is the 
pain that some children refuse to open the mouth or partake of food. 
I have seen the teeth become loose and necrosis of the alveolar 
process occur in places. Under the latter condition there is much 
swelling of the tissues above and beneath the jaw (lymph-nodes). 
The tonsils may also be the seat of ulceration of the same character 
as that occurring at the lateral margin of the tongue. 

Treatment. — Cleanliness is the first step toward lessening the 
intensity of the inflammation. The mouth is washed every three 
hours with a solution of potassium chlorate, made by adding a tea- 
spoonful of the saturated solution to a small glassful of water, or 
with a 0.5 per cent, solution of formalin. Internally, liberal doses 
of ferric chloride, made up with glycerin and water, have given the 
best results. If there are extensive ulcerative processes along the 
gums, the line of ulceration is gently touched once a day with a 10 
per cent, solution of silver nitrate. In addition, the patient must 
have an abundance of fresh air, and is given a nutritious fluid diet, 
with fresh fruits and a small allowance of wine. 



PSEUDODIPHTHERITIC STOMATITIS. 

This form of stomatitis was first accurately described by Epstein. 
It is seen in newborn infants who have sustained a traumatism of 
the mucous membrane of the mouth. An infection of the injured 
membrane with streptococci results in the formation of a membrane 
resembling that seen in true diphtheria. These cases occur in found- 
ling-hospitals and amid unhygienic surroundings. The pseudo- 
membrane is of a greenish-yellow hue, and may spread over the 
hard and the soft palate, the tongue, and the pharynx. It may 
involve secondarily the entrance to the larynx, as happened in the 
cases of Epstein, and the epiglottis and oesophagus as well. Gastro- 
intestinal symptoms and secondary septic pneumonia are developed. 
The temperature may, as in other cases of sepsis, be normal, or even 
subnormal. As a rule, the lymph-nodes are not enlarged. The 
condition must be differentiated from sprue and aphthous stoma- 
titis. Aphthous stomatitis does not show any pseudomembrane ; 
microscopical examination will aid in differentiating this disease from 
sprue. 

Treatment. — Inasmuch as these cases are of septic origin, their 
course is progressive. On the other hand, small patches of mem- 
brane may be limited by applications of a 10 per cent, solution of 
silver nitrate. The membrane should not be peeled off, nor should 
the mouth be washed out with the finger. Antistreptococcic serum 
is of no use in these cases. 



NOMA. 289 

GONORRHEAL INFECTION OF THE MOUTH. 

This affection, sometimes called gonorrhoea! or blennorrhceal stom- 
atitis, is an infection of the mucous membrane of the month by the 
gonococcus of Neisser. Infection occurs only in places where the 
mucous membrane has been injured. There may be an associated 
gonorrhoea! infection of the eyes or the vulva and vagina. The 
infection may be introduced into the month by the fingers of the 
nurse or mother. If the mother is suffering from gonorrhoea, infec- 
tion may occur at the time of birth or subsequent to parturition. 
The cases thus far reported (Rosinski, Kast) have developed from 
two to thirteen days after birth. 

Symptoms. — The constitutional disturbance is slight ; there is 
no fever, no pain, and no interference with suckling. The lesions 
occur on those parts of the hard palate most likely to suifer from 
traumatism and subsequent infection — the parts favored by Bed- 
nar's aphthae, the median raphe in the alveolar processes of the hard 
palate, and the anterior two-thirds of the tongue. Inspection reveals 
yellowish-white patches, due to infiltration of the superficial epithelial 
layers of the mucous membrane with inflammatory products. There 
is no pseudomembranous formation, but a pultaceous thickening. 
There is little tendency to spread, and no inflammatory reaction of 
the adjacent mucous membrane. The discharge is so slight that the 
saliva remains clear. 

Examination of the secretion from the patches on the hard 
palate (which are generally symmetrical) and on the tongue reveals 
the presence of abundant gonococci not only on the surface, but also 
invading the mucous membrane along the cement-substance between 
the epithelial cells. The infection differs from that seen in adults 
(Cutler), in whom great constitutional disturbance and severe inflam- 
mation of the whole mucous membrane of the mouth are combined 
with a profuse ichorous buccal discharge and with pain. The ten- 
dency is toward rapid recovery. 

The treatment is limited to the enforcement of strict cleanliness, 
arid to local applications of weak solutions of silver nitrate (2 per 
cent.). The mouth may be washed twice daily with a solution of 
protargol. 

NOMA. 

{Cancrum Oris.) 

Xoma is a specific bacterial affection which attacks the tissues of 
one or both sides of the face, resulting in gangrene and destruction 
of the soft and hard parts. Babes and Zambolovici differentiate it 
from all other form- of gangrenous stomatitis and gangrene, such as 
those described by Henoch as occurring on the vulva. 

19 



290 DISEASES OF THE MOUTH. 

The etiology is still obscure. Investigations thus far tend to 
show that several conditions clinically similar have been found to 
have a diverse etiology. Babes and Zambolovici isolated a very 
minute bacillus, and by inoculation experiments in animals produced 
typical noma. They found that this bacillus extends through the 
mucous membrane of the mouth, especially that of the gums. 
Accompanying it are a large number of streptococci, spirochetal, 
and other bacilli. The latter play an active secondary role in the 
production of the gangrene. Gangrene is caused by an over- 
whelming bacterial invasion of the tissues. The toxins produced 
cause death of cell-life and necrosis in mass. In another set of 
cases, Walsh found the bacillus of diphtheria. These cases would 
appear to correspond to those published by Freimuth and Pe- 
truschky, who found a bacillus identical with the diphtheria bacillus 
in cases of noma of the vulva. 

The greater number of cases of noma occur after measles. It 
may follow any of the exanthemata, typhus, typhoid fever, or 
any disease through which the power of resistance to infection is 
lessened. 

Symptoms. — Henoch and Baginsky hold that in many cases an 
ulcerative stomatitis has preceded the main affection. The disease 
begins on the mucous membrane and invades the cheeks from within. 
Henoch alone has seen it begin from without in the form of a phleg- 
mon of the cheek. It is first seen as a small ulcer with a blackish- 
gray base on the buccal mucous membrane opposite the teeth, or it 
may begin as a vesicle with serosanguinolent contents. After a 
period of time varying from a few hours to three or seven days the 
tissues of the cheeks become brawny and oedematous, the oedema 
involving the eyelids and lips. A dark, livid area finally appears 
on the corresponding exterior surface of the cheek. This area 
becomes black and gangrenous. Perforation and spreading of the 
gangrene rapidly result. The jaw may necrose and the teeth fall 
out. The process may spread downward along the neck, involving 
the shoulder in an oedematous, emphysematous, gangrenous mass. 
The indurations of the tissues of the cheek occurring in many forms 
of stomatitis ulcerosa should not be confounded with this affection ; 
in these forms of induration gangrene is absent. In all cases of 
noma a marked gangrenous odor pervades the atmosphere about the 
patient. 

The general condition of many cases is astonishingly good at 
first. The children seem unconcerned, and sit up in bed and play. 
The organism finally succumbs to the toxaemia accompanying such 
extreme destruction of tissue. There may be a febrile movement 
(103° to 104 c F., 39.4° to 40° C). The swallowing of gan- 
grenous products in some cases causes an intensely prostrating and 
uncontrollable diarrhoea of a septic character. There is little or no 



RIXGWORM OF THE TONGUE. 291 

pain. Death results within two or three weeks, either through 
general toxaemia and heart failure or complicating pneumonia. 

Occurrence and Prognosis. — From a study of the literature, 
noma is found to occur most frequently between the second and the 
seventh year. The mortality is very high — fully 75 per cent. 
(Woronichin). 

Treatment. — The most diverse methods have been employed in 
an endeavor to arrest the progress of the affection. To support the 
strength of the patient is the first consideration ; careful ventilation, 
antiseptic and deodorizing solutions to mask the gangrenous odor, 
good food, and wine, are all of service. 

The local treatment varies. Some authors advise dusting iodo- 
form on the gangrenous area ; others advocate the use of caustic 
zinc pastes in order to determine the line of demarcation between 
the gangrenous and healthy tissues. The Paquelin cautery with 
knife-blade attachment has been employed to remove the gangrenous 
tissue. Solutions of boric acid, thymol, and salicylic acid, should 
be freely employed to keep the mouth and parts clean. 

In those cases, probably a distinct set, in which the bacillus of 
diphtheria is found, the antitoxic diphtheria serum should be injected 
in proper doses. 

THE TONGUE. 

Congenital Anomalies of Size. 

(Macroglossia.) 

The tongue of some infants Avho are otherwise normal is unusually 
large and protrudes slightly from the mouth, but is of normal shape. 
It is pointed, but somewhat thickened in the middle (Fig. 88). As 
the infant grows older this anomaly becomes less apparent. In ex- 
treme cases the tongue protrudes from the mouth as a tumor mass. 
It is discolored — generally of a livid hue — and becomes ulcerated, 
especially at the line of the teeth. Infants thus affected cannot nurse, 
and the tongue must be reduced in size by surgical means. This con- 
genital enlargement of the tongue may be due to an increase either in 
the connective or muscular tissues, or in both. In other cases the 
lymph-spaces of part or the whole of the organ are dilated — there 
is a lymphangioma of the tongue. 

In cretins and the Mongolian forms of idiocy the tongue is also 
enlarged. It is broad, thick, and flat, and protrudes from between 
the lips. 

Ringworm of the Tongue. 

Wandering Rash of the Tongue; Lingua Geogmphira.) 

Ringworm of the tongue is a common affection of infants and 
children. It was probably first described by Santulus in 1854. 



292 



DISEASES OF THE MOUTH. 



Parrot regarded it as a symptom of hereditary syphilis — a view 
which has no clinical support. 

In 103 cases reported by Bohm, the condition occurred sometimes 
in early infancy, sometimes as late as the twelfth year of life, and was 
most frequent between the first and the second year. 



Fig. 88. 




Simple macroglossia. Infant, twelve months of age. 

The etiology is obscure. Bohm believes it to be connected with 
a lymphatic diathesis (scrofulosis). It is found chiefly among chil- 
dren of the lower classes. It may, however, be seen in children in 
good hygienic surroundings and who are otherwise healthy. 

If scrapings from the borders of the patches of an affected 
tongue be examined microscopically when fresh, large numbers of 
zooglsea of coccus form, in some cases mingled with sarcinse, will 
be seen. The presence of the latter micro-organism explains the 
yellow color of the border of the patches in some cases. The dis- 
ease sometimes affects several children of a family. 

The symptoms are limited to the appearance of the patches on 
the tongue. At the tip, but most frequently at the sides of the 
tongue, are seen areas sharply circumscribed by narrow, sinuous, 
perfectly oval or round borders (Fig. 89). The border is not only 
distinctly raised above the epithelium of the tongue, but also is of 
limited breadth and has a more pronounced whitish or yellow-white 



TONG UE-SWALLOWING. 



293 



color than the rest of the tongue 1 



is ovaJ 



the 



tongue seems 



Inside this border, if the patch 
to be denuded of its epithelium and is 
reddish in color. This condition should be differentiated from des- 
quamation of the epithelium on the dorsum of the tongue, which 
presents a similar appearance, but in which the patches have not 
the band-like border. Children do not appear to suffer inconven- 
ience from this condition of the tongue. 

Treatment of the most diverse kinds, including local application 
of tincture of iodine and the use of ferric chloride, has in my exper- 
ience failed to produce results. 



Fig. 89. 



Fig. 90. 





Ringworm or wandering rash of the 
tongue, lingua geographica. 



Epithelial desquamation of the 
tongue. 



Desquamation of the Epithelium of the Tongue. 

In this condition, which has been confounded with that just 
described, there are seen areas of irregular size and apparently 
denuded of epithelium. The boundary of these areas is sharply out- 
lined, but the epithelium bounding the areas is apparently normal 
(Fig. 90). The tongue looks as if the epithelium had been scraped 
off. The condition demands no treatment, since it is only a symp- 
tom of mild derangement of the digestive processes. 

Tongue -swallowing. 

Tongue-swallowing is a term applied to a peculiar phenomenon 
seen in sonic infants who are the subjects of nasal obstruction. 
Infants normally breathe through the nose when at rest, the tongue 
being in contact with the roof of the mouth. H nasal breathing is 
obstructed cither by swelling of the mucous membrane or by de- 
formity of bone, the infant experiences great difficulty in breathing 



294 DISEASES OF THE MOUTH. 

through the nose. As a result, not being accustomed to keeping 
the mouth open and the tongue on the floor of the mouth, the inef- 
fectual efforts at nasal and mouth-breathing cause the infant to draw 
the tongue inward. The tip of the organ folds on itself, and may 
be drawn backward into the mouth in the efforts at mouth-breathing, 
causing a peculiar snapping noise to be heard on inspiration. 

Treatment. — The remedy in these cases is nasal douching, and 
dilatation of the nasal passages with pledgets of cotton. The cotton 
is rolled around a probe or applicator, moistened with castor oil, 
introduced once a day into the nares, and allowed to remain about 
five minutes. 

Tongue-tie. 

Tongue-tie is a condition for the relief of which the physician is 
frequently consulted. Some mothers will ascribe inefficient nursing 
to this condition. With a breast secreting sufficient milk tongue-tie 
would not prevent nursing. The existence of the condition is readily 
detected if the organ is bifid at its tip when protruded. The frenu- 
lum will in such cases be seen to extend to the extreme tip of the 
tongue in a fan-shaped manner. 

Treatment. — The frenulum being membranous is easily divided. 
It should be caught in the bifid groove of the pocket-case director 
and made tense, and the membranous portion divided with a pair of 
round-ended scissors. The ends of the scissors should be directed 
to the floor of the mouth. There is little bleeding. The infant 
should be placed at the breast directly after the operation, so that 
the act of suckling may stop the hemorrhage. 



MALFORMATIONS OF THE UVULA. 

The uvula is often bifid in infants. This condition is only of 
anatomical interest. There are cases in which the uvula is relaxed 
and elongated. In one case, in a boy five years of age, the uvula 
was so long that it gave rise to an incessant night-cough. On ex- 
cision of the uvula the cough ceased. 

ACUTE RETROPHARYNGEAL ABSCESS. 

{Idiopathic Retropharyngeal Abscess ; Retropharyngeal Lymphadenitis.) 

The retropharyngeal space, according to Gillette, is the seat of 
several lymph-nodes, which are intimately connected with the lymph- 
-vessels and lymph-spaces of the tonsils, and also with the system of 
lymph-vessels of the soft palate, these being also connected with the 
deep lymph-nodes of the face and neck. Processes such as catarrhal 
angina, diphtheria, scarlet fever, measles, or any lesion of the mouth. 



ACUTE RETROPHARYNGEAL ABSCESS. 295 

are likely to involve the retropharyngeal nodes (Karewski). Some- 
times only the lymph-nodes in the median line of the retropharynx 
opposite the base of the tongue are affected. In this form the tumor 
in the midline is seen when the month is opened. In other cases sev- 
eral Lymph-nodes are involved, and the process is then seen both as 
a swelling in the mouth and as an external swelling at the side of 
the neck. 

The swelling appears at or beneath the angle of the jaw, in front 
of or behind the sterno-mastoid muscles. Retropharyngeal abscess 
may occur in the following forms : 

1. Acute retropharyngeal abscess: 

a. That which points wholly in the mouth. 

6. That which points both externally and internally. 

c. That which forms a tumor chiefly external. 

2. Chronic tuberculous retropharyngeal abscess. 

3. Septic retropharyngeal abscess. 

This third class of retropharyngeal abscesses are those which 
complicate or follow the exanthemata, and which have a tendency 
to burrow downward, bursting into the mediastinum or to involve 
important structures, such as the large arteries in the neck, thus 
causing fatal hemorrhage. A few such cases occur in the literature 
(Bokai). 

Frequency and Etiology. — Retropharyngeal abscess is peculiarly 
a disease of infancy and early childhood. The frequency diminishes 
in later childhood, the disease being rare after the fifth year. Of 
77 of my cases, 4 occurred between the first to the third month; 10 
between the third and the sixth month ; 41 between the sixth and the 
twelfth month ; 1 9 between the first and the fifth year, and the 
remainder after the fifth year. One infant was only one month of 
age, and in two cases the patient was two months of age. The 
figures correspond to those of Bokai. The frequency in early in- 
fancy is probably explained by the structure of the retropharyngeal 
Lymph-spaces and the susceptibility of the lymph-nodes to suppu- 
rative infections at that period of life. 

Simon has described the lymphatics in the retropharyngeal region 
of infants and children as forming a small network of lymph-vessels 
and node- on either side of the median line. This lymphatic; net- 
work is situated between the superior constrictor and the aponeurosis 
of the prevertebral muscles. After the third year of life these 
lymphatics and nodes are said to disappear. This fact, as Blackader 
points out, would indicate a close connection between the time of 
activity of these nodes and the period when retropharyngeal abscess 
i- most prevalent. It would help also to explain the absence of this 
form of abscess in older children and in adults who are frequently 
affected by tonsillar (quinsy) abscess. 

I have examined the pus from many of these ab.-eesses, and found 



296 DISEASES OF THE MOUTH. 

that it contains quite uniformly a streptococcus of the short or the 
long variety, not as a rule very virulent. It may be assumed that in 
all probability these bacteria are the essential cause of the abscesses. 
They gain access to the retropharynx either through the tonsils or 
the mucous membrane of the pharyngeal space. The abscess may 
thus be secondary to any form of inflammation of these structures. 
It occurs as a complication of simple tonsillitis, pharyngitis, influenza, 
or any of the exanthemata. 

The symptoms of retropharyngeal abscess are not at first dis- 
tinctive. The development of the abscess is insidious. At the out- 
set there are the symptoms of ordinary tonsillitis or pharyngitis. 
The fever is high at the beginning. After the acute symptoms sub- 
side it is noticed that the lymph-nodes at the angle of the jaw con- 
tinue to be enlarged, and that the fever continues to show a remittent 
type. There is some prostration, the infant does not nurse properly, 
cries, and is frequently restless. Inspection of the throat on the 
fourth or fifth day of a tonsillitis may reveal nothing except some 
swelling or oedema of the posterior pharyngeal wall or of the 
pillars of the fauces, no tumor being visible. After an interval 
of a few days, generally on the seventh or eighth after the initial 
symptoms, it is noticed that the voice of the infant has a nasal 
quality, that the head is thrown back, and that the breathing is 
noisy and nasal. Examination shows that the lymph-nodes at 
the angle of the jaw in front or behind the sterno-mastoid are 
swollen ; inspection of the interior of the fauces shows a distinct 
swelling at the side of the pharynx pushing the tonsil and pillar of 
the fauces of that side forward. On introducing the finger a tense, 
fluctuating swelling, which may reach downward toward the larynx, 
can be felt. In other cases there is very little external swelling, 
and the internal tumor is situated nearer the median line, pushing 
the posterior pharyngeal wall forward. This swelling is covered by 
mucous membrane, is tense and fluctuating. If the tumor is allowed 
to increase in size, there is pronounced interference with the breath- 
ing. I have seen cases in rachitic infants in which the inspiratory 
sound was distinctly of a crowing character, showing incoordinate 
action of the vocal cords. These cases show great prostration and 
feebleness of pulse. 

Course. — If not treated, the abscess may press on the larynx and 
cause asphyxia, or may burst spontaneously into the larynx, suffo- 
cating the patient if it occurs during sleep, or may burst into the 
ear through the Eustachian tube and discharge externally. All of 
these results are rare if the abscess is detected in time for incision. 

The diagnosis of retropharyngeal abscess is difficult to the be- 
ginner, but is simple after the observation of one or two cases. The 
quality of the voice and the cry are so characteristic that after being 
once heard they are unmistakable. The breathing also is typical. 



ACUTE RETROPHARYNGEAL ABSCESS. 297 

The external swelling is present in most cases, and the head slightly 
retracted. Finally, digital examination should always be resorted to 
in all cases in which a slight or marked internal swelling is present. 
The index finger of the right hand is passed into the month and the 
posterior pharyngeal wall palpated. If an abscess be present, it 
will be apparent as a hard or tense, globular, deep or superficially 
fluctuating tumor. Care should be taken not to mistake the promi- 
nence of the body of the seventh cervical vertebra? for an abscess. 
The bony tumor is deeper, as a rule, than the retropharyngeal 
abscess, and is not fluctuating. All manipulation should be carried 
out gently, else the abscess may burst and suffocate the patient or 
rude exploration may cause a peculiar form of collapse which some- 
times follows digital examination in this region. 

The prognosis of simple acute retropharyngeal abscess is good. 
Bokai lost only 4 per cent, of his cases. With early diagnosis and 
proper treatment recovery is the rule. 

The treatment of acute retropharyngeal abscess is incision. This 
varies with the nature and location of the abscess. In the majority 
of cases the abscess is near the median line, and its wall is just 
beneath the surface of the mucous membrane. An internal incision 
will then afford immediate and permanent relief. In other cases the 
abscess is at one side and internal, and may also be safely incised from 
within. In making an internal incision the following method should 
be pursued : the child is wrapped in a blanket and held upright in 
the lap of the nurse, facing a good light. An assistant steadies the 
head from behind. The tongue is depressed with a tongue-depressor, 
and a bistoury, with the edge guarded by rubber plaster, leaving 
only a half inch of the tip exposed, is plunged into the most promi- 
nent part of the tumor. When the pus escapes, the incision is 
enlarged from above downward. The instrument should not be 
directed toward the side of the neck, for fear of wounding a vessel. 
As soon as the pus escapes freely the head of the infant is thrown 
forward and the pus allowed to drain into a basin, pressure being 
made from without, on the side of the neck. The internal incision 
should be made as rapidly and as gently as possible. I have seen 
death result within a few hours from aspiration of pus in a case in 
which an abscess burst as a consequence of rough digital explora- 
tion. If necessary, the incision may be enlarged with a dressing- 
forceps. In some cases the wound should be prevented from clos- 
ing by introducing the forceps daily. 

There is another class of eases in which the dee]) cervical glands 
at the side of the neek are involved and the abscess points partly 
internally and partly externally. In these cases it is unsafe to 
incise from within, nor is complete relief afforded by so doing. 
r \ lie ;il>-«-* — should be approached from without through a careful 
dissection by a -killed surgeon. The tuberculous abscess is due to 



298 DISEASES OF THE MOUTH. 

spinal caries, and is best opened and drained from without, as are 
also septic abscesses. 

RETRO-GESOPHAGEAL ABSCESS. 

Retro-oesophageal abscess is a rare affection of infancy and child- 
hood. Crozer Griffith has noted 15 cases in the literature. His 
own case was that of a child twenty-one months of age. The cause 
of the abscess was caries of the lower cervical and upper dorsal ver- 
tebra?. 

The symptoms are obscure, and in the majority of cases no 
diagnosis was made. The principal symptom is a harassing cough 
persisting for several months, finally becoming croupy and brassy. 
In the final stage the dyspnoea causes marked diaphragmatic retrac- 
tion of the lower part of the throax. There is no dysphagia and 
no such change in the voice as in retropharyngeal abscess. Inspec- 
tion of the throat may reveal a slight external swelling over the 
cervical or dorsal vertebrae. 

Treatment. — If abscess is diagnosed or suspected, an incision 
should be made along the oesophagus, and the abscess drained from 
the outside. 

ADENOID VEGETATIONS. 

It is not within the scope of this work to give more than the 
diagnostic bearings of these growths as they occur in infants and 
children. On inspection, the posterior nasopharynx in the normal 
infant is frequently seen to be the seat of more or less adenoid 
tissue. The diseased condition is simply an exaggerated growth of 
the tissue which is normally present in this space. Clinically there 
are three distinct classes of cases that suffer from adenoids : 

The first class comprises those in which the adenoids cause few 
or no symptoms. The children when in good health breathe 
through the nose and keep the mouth closed during sleep. They 
are peculiarly susceptible to slight colds or catarrh, and when thus 
affected the tonsils enlarge, the nose becomes obstructed by secretion, 
there is difficulty in breathing, and the patient sleeps with the mouth 
open. On the subsidence of the inflammatory condition the normal 
status is re-established. The children are subject to recurrent 
attacks of tonsillitis, and with each recurrence the symptoms of 
adenoids become more marked. The patients contract obstinate 
coughs which resist all treatment, and epistaxis occurs from causes 
apparently trivial. 

The second class of cases comprises those in which, in addition to 
the enlarged tonsils, there are enlarged lymph-nodes in various 
regions of the body. The patients are pale and present all the 



ADENOID VEGETATIONS. 299 

symptoms of lymphatism. Their voices have a nasal intonation, 
the lips are always parted, and they sleep with the mouth open 
(mouth-breathers). 

The third class comprises the genuine cases of adenoids. The 
nasal passages are the scat of a chronic hypertrophic rhinitis, the 
tonsils are enlarged, there is obstructed breathing, and the mouth is 
always open. The infants and children make a peculiar snarling 
sound in breathing and have a stupid look. They are not neces- 
sarily lymphatic. Many children suffering from adenoids are slightly 
deaf, and all are subject to repeated catarrhal attacks. 

Between the extremes are seen all gradations of the affection. 
Many children who suffer from adenoids are well developed and in 
other respects perfectly normal. The deformities of the chest which 
have been ascribed to adenoids can hardly be so regarded. They 
are coincidental. Many of them are due to rachitis in early life 
and to unhygienic living. To trace enuresis, chorea, and mas- 
turbation to the presence of adenoids, seems also somewhat ex- 
treme. Adenoids are an obstruction to the breathing, a menace 
to the hearing, and also a focus for repeated infections of the 
nasopharynx or the ears. These are sufficient reasons for their 
removal. 

The diagnosis of the condition is made from the above symp- 
toms, and also by digital exploration. Care should be taken that 
the finger used in exploring the posterior nasopharyngeal space is 
very clean and that the nail is smoothly trimmed. The parts should 
not be traumatized unnecessarily. The index finger passed up and 
behind the soft palate encounters soft masses of adenoid tissue which 
bleed easily and are readily crushed. They are sometimes peduncu- 
lated, and may be attached to the roof of the nasopharyngeal space 
or to the posterior portion of the Dares. Some authors have ad- 
vised the use of a shield in exploring this space. The skilful 
laryngologist prefers to use the mirror in examining these parts, 
and protests against the digital method. 

The treatment of adenoid vegetations belongs to the special field 
of the nose and throat. 

Contraindications to Operations. — The tonsils and adenoids being 
portals of infection, there are certain states in which operations in 
this region may be followed by reinfection. Thus cases of chorea 
with endocarditis, if still active, should not be subjected to operation. 
The chorea is likely to recur with greater severity, and the danger 
of a renewed heart lesion is great. Children who are in the active 
stages of endocarditis or recently recovered should not be operated 
upon. In all these cases palliative measures, such as sprays and 
douches, should be employed until the conditions above mentioned 
are thoroughly quiescent. In one case of chorea I saw an operation 
for adenoids followed in three days by a chill and high fever, eudo- 



300 DISEASES OF THE MOUTH. 

pericarditis, chorea "insaniens, and death within ten days. While 
such cases are exceptional, they teach the necessity of caution in 
deciding to operate upon the adenoids in chorea and heart cases. 



THE TONSILS. 

The tonsils are really lymph-nodes, as has been shown by Stohr 
and Hodenpyle. In severe forms of inflammation they are en- 
larged and the so-called crypts become plugged with bacteria and 
the products of inflammation (leucocytes, fibrin, serum). The crypts 
appear at the surface of the tonsil as yellowish specks. A catar- 
rhally inflamed tonsil may not show them at the surface, because the 
products of inflammation do not coagulate, and are thus thrown off 
more readily. There is nothing specific about a lacunar or follicu- 
lar amygdalitis. It is only a clinical picture of the large class 
of catarrhal inflammations, in all of which the crypts and the 
tissue of the tonsil are infiltrated with inflammatory products. 

Acute Follicular Amygdalitis. 

(Acute Catarrhal Tonsillitis; Acute Lacunar Amygdalitis ; Catarrhal Angina.) 

Acute follicular amygdalitis is an infectious disease, communi- 
cable either through the secretions or by direct contact, as in the act 
of kissing. It occurs both as a primary and as a secondary affection. 
As a primary affection, it occurs at all periods of infancy and child- 
hood. It was formerly taught that follicular amygdalitis was rare 
in infants. This is scarcely true. Of 1284 cases of lacunar amyg- 
dalitis, 333 occurred in infants under the age of twelve months, and 
76 from the first to the fifth month ; of the latter, only 5 occurred 
in the first month. It is frequent in children from the second to 
the fourth year, but is more common after than before the fourth 
year. The tonsils are secondarily involved in the exanthemata — 
scarlet fever, measles, and varicella — and in parotitis, influenza, pneu- 
monia, and pertussis. In all these affections they are reel, swollen, 
and in some cases present the appearance seen in the typical lacunar 
type of the disease. 

Etiology. — The predisposing causes of catarrhal tonsillitis or 
lacunar amygdalitis are exposure to cold, traumatism, and the swal- 
lowing of corrosive or irritant substances. The exciting causes of 
follicular or lacunar amygdalitis and catarrhal amygdalitis are the 
Streptococcus pyogenes, the Staphylococcus pyogenes, and the pneu- 
mococcus. The diplococcus described by Roux is also found in the 
tonsillar crypts. 

Symptoms. — The affection rarely begins with a chill. The 
infant is restless, peevish, and wakeful at night ; it breathes rapidly, 
and there are high fever and marked prostration. Nursing is in- 



ACUTE FOLLICULAR AMYGDALITIS. 301 

terfered with, not only on account of the pain in swallowing, but 
because in the majority of cases there is more or less rhinitis 
present. As a rule, the bowels are disturbed as a result of swallow- 
ing infectious secretions from the mouth with the food. The action 
of the bacteria in the gut is manifested in green stools, which are 
frequent and watery. Inspection of the throat should be conducted 
with patience and in a good light. The tonsils, normally very 
small, are seen to be enlarged and studded with whitish or yellowish- 
white points. The lymph-nodes at the angle of the jaw may be 
enlarged. 

In older infants and children the tonsils are enlarged, and the 
crypts plugged with inflammatory products. The surface of the 
tonsils is covered with mucopurulent exudate, or there may be a 
small necrotic, ulcerated area in one of the tonsils. The neighboring 
structures, such as the uvula, the pharyngeal mucous membrane, 
the pillars of the fauces, and even the larynx, may share in the 
catarrhal inflammation. The lymph-nodes at the angle of the 
jaw may be enlarged. The fever, as a rule, is high at first, ranging 
from 104° to 105° F. (40° to 40.5° C.) or above. The pulse is 
correspondingly rapid, and the respirations may be increased in fre- 
quency. 

The duration of a typical case of primary tonsillitis varies. As 
a rule, the temperature remains high for two or three days, with 
daily remissions. It then subsides and the patient convalesces. In 
some cases the temperature continues high for five or ten days, and 
then drops. In all of these cases there is some latent or apparent 
complication, such as retropharyngeal abscess, otitis, or, as has been 
recently pointed out by Packard and others, an insidious endocarditis. 
When otitis supervenes the tonsillar affection subsides. The fever, 
however, continues, with daily remissions. As a rule, infants and 
young children do not indicate the existence of pain in the ear. The 
patient is restless at night, and wakes with a start or in a peevish 
mood. In many cases the otitis can be diagnosed only by exclu- 
sion. In other cases the temperature continues high for a week or 
longer, reaching 103.5° F. (39.7° C.) during the day. The infant 
seems weaker, the tonsils are not enlarged or severely inflamed, the 
pulse is accelerated, and the respirations may number 40. In such 
cases the lungs show no sign of involvement, but careful examina- 
tion of the heart will often reveal the presence of a systolic murmur 
at the apex and a slight increase of the area of cardiac dulness 
beyond the nipple. These are the so-called rheumatic cases. Fre- 
quently the urine shows a trace of albumin. In rare cases it con- 
tains in addition to the albumin elements pointing to parenchymatous 
irritation of the kidney. T saw a case recently, in a child six years 
of age, in which after a mild attack of tonsillitis there were a 
tew casts, blood-cells, and a small amount of albumin in the urine. 



302 DISEASES OF THE MOUTH. 

Months elapsed before the urine ceased to show evidences of the 
nephritis. In these cases the albuminuria may assume the so-called 
cyclic character. 

The prognosis of simple catarrhal tonsillitis is good, recovery 
taking place in a few days. On the other hand, tonsillitis is not 
the simple entity formerly supposed. In infants and children this 
is especially true. The physician should be watchful for possible 
complications and sequelae, such as otitis, retropharyngeal abscess, 
endocarditis, and nephritis. 

The diagnosis of tonsillitis is usually a simple matter. If an 
infant refuses the breast and the temperature is elevated, the throat 
should be carefully inspected. It is good practice to make a bac- 
teriological culture with the secretions from the throat, even though 
the appearances are not diphtheritic at the first visit (for technique, 
see section on Diphtheria). 

The treatment of acute tonsillitis is symptomatic. Sponging 
with cold water or water at 85° F. (29.4° C.) containing a dash of 
alcohol, will lower the temperature. A dose of quinine should be 
given twice daily, and if the lymph-nodes at the angle of the jaw. 
are enlarged, cold applications should be made externally. Sprays 
are not required unless there is a harassing cough. Dobell's solu- 
tion sprayed three times daily will relieve that symptom. In 
nursing infants the number of feedings by the breast or bottle is 
reduced. If there is disturbance of the bowel, a teaspoonful of castor 
oil or grain \ (0.03) of calomel, given twice daily, will empty the 
bowel. The infant is then dieted on albumin-water or barley- 
water, or a solution of acorn cocoa or beef-juice and barley-water, 
until the intestinal irritation has disappeared. A return to a 
milk diet may be made as soon as the movements become normal. 
Small doses of ferric chloride have a beneficial effect on older 
children. In mixture form it is an excellent local application 
to the tonsils. The custom of giving potassium chlorate in this 
mixture is now generally abandoned, the drug being highly irri- 
tant to the kidneys. In nursing infants ferric chloride causes 
diarrhoea. For this reason it should not be administered to them 
for long periods. 

Herpes of the Tonsils. 

Herpes of the tonsils are small vesicular formations seen on the 
anterior pillars of the fauces, just in front of the tonsils. They 
occur in a number of slight febrile conditions, may accompany an 
angina of a simple type, and are part of the clinical picture of aph- 
thous stomatitis. The vesicles burst, leaving yellowish ulcerations 
of the size of a pin's head and surrounded by a pink areola. They 
heal without treatment after a few days. 



ACUTE CATARRHAL LARYNGITIS. 303 

THE LARYNX. 

Acute Catarrhal Laryngitis. 

(Catarrhal Croup; Spasmodic Croup; Spasmodic Laryngitis ; Pseudocroup.) 

Etiology. — Exposure to cold or wet are predisposing causes. 
Like the majority of catarrhal inflammations of the respiratory pas- 
sages, .acute catarrhal laryngitis is due to the invasion of bacteria. 
It occurs as a primary affection, and in a modified form is met with 
secondarily in measles and influenza. The classical form of 
"croup" is a primary affection, and is most common from the 
second to the fifth year. It is also seen in very young infants. One 
attack predisposes to others. 

Symptoms. — Catarrhal croup or catarrhal laryngitis is an affec- 
tion that causes much concern to mothers when a first attack develops 
without warning. During the day the infant may have had a mild 
coryza with a slight elevation of temperature. Toward evening a 
croupy cough, accompanied by croupy breathing or voice, suddenly 
develops. In some cases the symptoms remain mild, and only the 
cough disturbs the patients. They breathe freely, and dyspnoea is not 
marked. In other cases the infant or child goes to sleep free from 
alarming symptoms. Coryza may have been present unnoticed 
during the day. During the night the patient awakes with a croupy 
cough, which rapidly becomes worse. The breathing is noisy (croupy), 
and may be heard in an adjoining room. The cough is especially 
terrifying. The patients are restless, and cry during the paroxysms 
of coughing. In some cases they sit upright and gasp for breath. 
The face is pale and wet with cold' perspiration. Fever may be 
slight or marked. In the majority of cases the dyspnoea is real ; 
there is drawing inward of the suprasternal region and the peri- 
pneumonic groove at the epigastrium. Toward morning the dysp- 
noea, cough, and breathing subside, and the patients fall asleep, worn 
out with the night's suffering. The next day the patients are 
apparently well, with the exception of a slight cough, coryza, swollen 
tonsils, with redness of the pharynx. For two or three successive 
nights there may be a repetition of the attack. This condition 
should be differentiated from laryngismus stridulus. In the latter 
there is no fever, the breathing is stridulous during only a short 
spasmodic attack, and there is no croupy cough. On the other 
hand, pseudocroup may occur in children who are rachitic and the 
subjects of laryngismus. There are forms of diphtheritic laryn- 
gitis without the formation of membrane, which in their symptoma- 
tology are identical with the form of laryngitis above described. 
This is true in very young infants and in children above five years 
of age. A culture-test is the only certain mode of differentiating 
the affections. The pathological condition giving rise to pseudo- 



304 DISEASES OF THE MOUTH. 

croup is believed to be a swelling of the mucous membrane beneath 
the vocal cords. 

Treatment. — The patient should be isolated. The crib should 
be placed under an improvised tent, and the tent filled with steam 
vapor saturated with benzoin or turpentine. Grains x (0.6) of calo- 
mel should be sublimed every two hours underneath the tent, as in 
diphtheritic laryngitis. This treatment is efficacious in the majority 
of cases, the croupy cough and breathing abating after the first inhala- 
tion. Turpeth mineral is a favorite remedy with many practitioners. 
An emetic is seldom necessary. I have never practised intubation 
in these cases. Although the dyspnoea was extreme, cyanosis was 
not present in the cases I have seen. Cases have been recorded in 
which resort was had to intubation to relieve dyspnoea and laryn- 
geal obstruction. In such cases the suspicion is warrantable that 
there was diphtheritic invasion of the larynx. 

Leading Authorities Referred to in Chapter IY. 

Babes and Zambolovici : Annales d'Instit. de Path., etc., Bucarest. 
Bernheim : Centralbl. f. Bakt., 1898. 
Bishop and Ryan: Jour. Amer. Med. Assoc., 1902. 

Blackader: " Betropharyngeal Abscess," Montreal Med. Jour., 1888-1889, voL 
xvii. 

BoJcai, I., Jr. : Paediatrische Arbeiten Henoch, 1890. 

Crozer Griffith : " Ketro-cesophageal Abscess," Trans. Amer. Pediat. Soc, 1901. 
Epstein : " A Pseudodiphtherie," Jahrb. f. Kinderheilk., Bd. xxxix. 
Forcheimer : Archives of Pediatrics, 1892. 

Freymuth and Petruschhy : Deutsch. med. Wochenschr., 1898, No. 38. 
Friihwald: Jahrb. f. Kinderheilk., Bd. xxix. p. 200. 

Mayer.Em.il: "Affections of the Mouth and Throat," etc., Amer. Jour. Med. 
Sciences, 1902. 

Niclot and Marotte: Kev. de Medecine, 1901. (Vincent's bacillus.) 

Rosinsky : Zeitschr. f. Geb. u. Gyn., Bd. xii. 

Walsh: "Noma," Jour. Amer. Med. Assoc, 1902. 
Sobel and Herrman : N. Y. Med. Jour., 1901. 

Vincent: Annal. del'Instit. Pasteur, 1896. 

Woronichin : Jahrb. f. Kinderheilk., Bd. xxvii. 



CHAPTER V. 

DISEASES OF THE GASTROENTERIC TRACT. 

PHYSIOLOLICAL AND ANATOMICAL FACTS CONCERN- 
ING DIGESTION IN INFANTS AND CHILDREN. 

The reaction of the secretions of the month in the newly born 
infant, before it has partaken of food, is neutral or slightly alka- 
line (Ritter, Contaret, Korowin, Czerny). Little saliva is secreted. 
The gland secretion of the parotid contains ptyalin ; that of the sub- 
maxillary gland possesses converting powers only after the second 
month (Montagne). 

THE STOMACH. 

The oesophagus enters the diaphragm at about the level of the 
ninth dorsal vertebra ; the cardia is on a level with the tenth dorsal 
vertebra; the pylorus is in the majority of cases situated in the median 
line, but in some cases is slightly to the right of it. It is midway 
between the tip of the ziphoid cartilage and the umbilicus, and, being 
behind the liver, is not palpable. The stomach lies in an oblique 
position, passing from behind forward and ('own ward. The pylorus 
i< from two to two and one-half bodies of a vertebra lower than 
the cardia. In the newly born infant the inferior portion of the 
stomach has a fundus form (Pfaundler), which later becomes more 
marked. Occasionally there is no fundus, and the stomach is then 
of cylindrical shape. Between the time of birth and the seventh 
month the fundus of the stomach increases to fully twice its original 
length (Pfaundler). 

The capacity of the stomach is still a matter of speculation. The 
absolute capacity, as given by Fleischman, Drewitz, Pfaundler, 
Holt, and Rotch, varies with the method employed to determine it. 
The work thus far done has been carried out on the cadaver, and, 
moreover, the methods employed presuppose an amount of pressure 
(14 c.c. to 30 c.c.) of water which does not exist in the normal 
state during life. The stomach contracts after death (systole) ; the 
distention with air or fluids i- thus partly artificial. Lastly, the 
stomach capacity is of little aid in determining the point at issue 
— the quantity of food which should be taken by a healthy infant 
at each feeding. Figures giving absolute stomach capacity are use- 

20 305 



306 DISEASES OF THE GASTRO-ENTERIC TRACT. 

ful only as indicating the actual size of the organ when full of fluid, 
a condition rarely present during life. 

The following table is compiled from the sources mentioned. 
Pfaundler's results, which were obtained by careful computation, 
differ widely from those of others. They were obtained by post- 
mortem distention with fluid at a pressure of 30 c.c. of water. 
Fleischman distended the stomach at 14 c.c. of water pressure. 

Fleisch- Drewitz. Pfaund- Rotch. Holt. 

MAN LER. 

C.C. C.C. cc. c.c. c.c. 

At birth 30 . . 30 30 36 

One week 45 

One month 77 99 150 75 60 

Two months 79 115 175 96 99 

Three months 140 130 200 100 135 

Four months 165 230 107 150 

Five months 290 253 260 108 170 

Six months 260 297 295 . . 264 

Seven months 217 330 

Eight months . . 289 365 

Nine months 510 406 

Ten months 375 350 445 

Eleven months 535 485 . . 243 

Twelve months 500 515 

One to two years 220 588 640 

Function and Motility. — The stomach of breast-fed infants 
empties itself in two hours after the ingestion of a full nursing. If 
the quantity of milk taken is small, a shorter time suffices. Bottle- 
fed infants taking cows' milk need fully three hours to accomplish 
the same result. This fact alone teaches that intervals of rest be- 
tween the nursings, and a rest of four or five hours once in twenty- 
four hours, are necessary. 

Reaction. — When digestion is not in progress the stomach con- 
tains a tenacious colorless mucus, neutral in reaction. When food is 
in the stomach, the reaction is acid. 

Hydrochloric acid is normally present in the stomach of the in- 
fant (Leo, Van Puteren, Wohlman) ; lactic acid only occasionally. 
Heubner found 0.16 to 0.2 pro mille of lactic acid present. A 
considerable amount of hydrochloric acid unites with the salts and 
albumin of the milk, and is found as combined hydrochloric acid. 
When combination is no longer possible, the residue appears as 
free hydrochloric acid. The amount of free hydrochloric acid 
depends on the quantity of milk ingested, and varies from 
0.8 to 2.1 pro mille. I have frequently failed to find it in the 
stomach contents of infants who are fed irregularly at frequent 
intervals. In healthy breast-fed infants free hydrochloric acid is 
found in from one and a quarter to two hours, and in bottle-fed in- 
fants in from two to two and a half hours after nursing. The effect 
of the lab-enzyme on the milk is marked in breast-fed as compared 



INTESTINAL FERMENTS. 307 

with that in bottle-fed infants. In the former the action of the acid 
delays that of the lab-ferment fully an hour after feeding, while in 
the latter coagulation of the casein occurs at once and in large 
flocculi. The difference in the retarding action of the lab-ferment is 
due to the increased alkalescence of mother's milk, which requires 
more acid to neutralize the alkali, and thus to render coagulation 
possible: hence the greater digestibility of mother's milk and the 
rationale of adding lime-water to cows' milk for infant use. 

Gastric contents containing free hydrochloric acid are antiseptic, 
while combined hydrochloric acid has no such properties. 

In newly born infants lab-enzyme is present in minute quantities 
(Raudnitz) ; it is more abundant in older infants (Leo). 

Pepsin is present in the stomach of the newly born infant (Ham- 
marsten, Zweifel), as is also peptone (Leo, Van Puteren). 

Marking out the Stomach by Percussion. — This procedure is 
difficult with infants and children. The normal stomach is rarely 
found outside of the left hypochondrium. The liver fully covers 
the stomach in the collapsed state. In the recumbent posture 
the stomach may be mapped out on the anterior abdominal parietes. 
It comes forward in the triangle formed on one side by the bor- 
der of the left lobe of the liver and on the other by the border 
of the ribs. Above, the apex of the triangle is formed by a 
junction of the ribs and left lobe of the liver. Below, the base of 
the triangle is of variable length. In the axillary line the fundus 
in a moderately distended state is in contact with the thoracic walls, 
between the liver above and the spleen below. Above, it is sepa- 
rated from the lung resonance by a strip of dulness (the left lobe of 
the liver) which changes position with the movements of the dia- 
phragm. The tympanitic resonance reaches downward in a vertical 
direction from the sixth to the eighth rib. Behind this, tympany is 
limited by the posterior axillary line ; in front, by the triangle above 
referred to. I have frequently been able to confirm these statements 
of Fleischman. Anteriorly, I have with the aid of a gastrodia- 
phane shown that the transverse colon passes in front of the stomach 
jost beneath the liver. It should be remembered that tympanitic 
resonance in the epigastrium is not always due to the stomach. 



INTESTINAL FERMENTS. 

Little is known of the functions of the intestinal glandular appa- 
ratus. Many facts have been established as to the changes caused 
by the action of the secretions of the larger glandular organs on the 
food. 

The liver, a very important organ in the newborn infant, is 
capable of forming glycogen. 



308 DISEASES OF THE G ASTRO-ENTERIC TRACT. 

The gall-bladder in the newborn infant is filled with a clear 
yellow secretion. 

The pancreas is fully formed at birth ; during the first three 
weeks the pancreatic juice has probably no converting action on 
starch (Korowin). After the twenty-fourth day, Zweifel found a 
ferment in the pancreatic juice capable of converting starch. This 
action is supposed to be independent of any action of the intestinal 
bacteria. The enzyme invertin is found in the wall of the small 
intestine, and its inverting action on milk-sugar is apparent in the 
newborn infant (Pautz and Vogel). Lactase capable of inverting 
lactose is found in the feces of the nursing infant (Orban). Milk- 
sugar is from earliest infancy fully converted in the gut and ab- 
sorbed (Czerny). 

The Bacteria. — Although the morphological and biological 
characteristics of the bacteria of the mouth, stomach, and intestine 
have been extensively studied, little is known of their physiological 
effects on the food during its passage through the gastro-enteric 
tract (Czerny). 



CHARACTERISTICS OF THE STOOLS OF INFANTS. 

This subject has been treated in a general way in the chapter 
on Hygiene. In addition, it may be noted that the movements 
of bottle-fed differ from those of breast-fed infants in that they are 
of a lighter color and in the main more bulky. In a perfectly 
normal breast-fed infant the movements may at times vary in color 
and general consistency. Gregor has accounted for this by assuming 
that the stool of the infant at the breast will vary because the com- 
position of the -nurse's milk varies not only from day to day, but 
also at different hours of the day. The movements of the breast- 
fed infant will thus at times contain small white or greenish curds 
or watery elements without the existence of any disturbance of the 
general health. The character of the movements of bottle-fed in- 
fants will vary with the food taken. Infants taking a malted food 
will have movements that are dry and broken up into crumbs, and 
have a distinct odor of malt. The feces of the breast-fed infant 
have a distinctly acid odor, while those of the bottle-fed infant have 
an odor of decomposition (Czerny). In general the feces of infants 
may be said to contain digested absorbable substances, indigestible 
substances, products of digestion and decomposition, anatomical 
elements of the digestive organs of the stomach and gut, cellular 
elements, and bacteria. 

If the movements of the breast-fed infant are closely examined, 
they are found to contain small whitish-gray particles, the so-called 
milk granules of Uffelmann. These were at first thought to be 



ACUTE GASTRIC DYSPEPSIA. 309 

composed of casein ; it is now known that they are made np of fat 
and fat-crystals or zoogloea of bacteria. In addition, there are found 
in the feces of infants epithelial elements, bilirubin crystals, and 
cholesterin plates. Fat appears in the feces of infants rarely as fat- 
globules, but generally as fatty acids, neutral fats and soaps. The 
movements of infants on a mixed diet contain free starch-granules, 
cellulose, and also cholesterin-plates and bilirubin. 

The products of decomposition — indol, skatol, and phenol — are 
also found according to the time which has elapsed since the void- 
ance of the movement (Blauberg). 

Sugar is not found in the feces of infants, or only in small quan- 
tities (Uffelmann, Blauberg). 

Michel has found that the gross weight of feces in the newborn 
breast-fed infant was about 1.5 per cent, of the gross quantity of 
food ingested, while later in infancy the movements were 2.7 per 
cent, of the amount of food iugested. Rubner and Heubner found 
that in bottle-fed infants the feces were about 7.4 per cent, of the 
total amount of food ingested. 

Michel found that the amount of water in the feces in the first 
days of infant life was about 72 per cent., while at the ninth month 
it was So per cent. (Uffelmann). 



ACUTE GASTRIC DYSPEPSIA. 

(Indigestion.) 

Acute gastric dyspepsia may clinically be divided into two forms, 
that affecting infants, and that affecting older children. The period 
of infancy is one of frequent disturbances. Mental excitement on 
the part of the nurse may cause the milk to disagree with a breast- 
fed infant. The ingestion of an undue quantity of breast-milk, 
even if of good quality, may cause indigestion. Certain articles 
of food, notably asparagus, if partaken of by the mother, may cause 
gastric irritation. Nursing a breast in which the milk has caked 
will also cause indigestion. 

Symptoms. — Vomiting is the first evidence of disturbance of 
the digestive processes in the infant. It occurs after feeding, and 
is at first not accompained by constitutional Bymptoms or diarrhoea. 
If the exciting cause continue-, a slight febrile movement is noted, 
and also slight prostration. The infant is restless, but having vom- 
ited i< relieved, and if permitted will again take the breast, the vom- 
iting taking place after each nursing. The bowel movements then 

become disturbed. They may not only be green, but also frequent 

and in Borne cases fluid. There are in all cases colic and tympanites. 

Acute gastric dyspepsia in older children may be caused by some 

article of diet which has disagreed with the patient. The symptoms 



310 DISEASES OE THE GASTRO-ENTERIC TRACT. 

are much the same as those seen later in life. It is important both 
with infants and children to determine whether the symptoms are 
due to improper food or whether proper food has for some reason 
disagreed. Bottle-fed infants are liable to indigestion if the milk 
contains any extraneous substances, not necessarily toxic ones. 

A baby may have thrived for weeks on a certain food-mixture, 
when suddenly, without apparent cause, symptoms of gastric dys- 
pepsia supervene. In such cases it will be found that the acidity of 
the milk was greater than usual, or that the fodder of the cow has 
been changed. 

Course. — If the giving of food is suspended and proper treatment 
instituted, the symptoms subside and the infant recovers, but if the 
exciting cause is not removed, more serious disturbance of the stomach 
and gut will develop. 

Treatment. — It is best both with breast-fed and bottle-fed infants 
to discontinue the giving of all food as soon as symptoms of indi- 
gestion appear. With the suspension of food the administration of 
a simple cathartic (castor oil) is all that is necessary. The infant is 
put for twelve hours on a solution of white of egg, and the breast 
pumped regularly every three hours to prevent caking. The breast 
may then cautiously be exhibited. Stomach washing should not be 
resorted to, and the breast should not be denied for too long a period. 
If, on resuming breast-feeding, symptoms reappear, an analysis of 
the milk should be made. Its composition may have changed and 
too much fat may be present. We should not be hasty in taking an 
infant from the breast and placing it on the bottle on account of a 
few T symptoms of gastric dyspepsia. Proper regulation of the diet 
and the taking of proper exercise by the nurse will frequently cause 
the desired adjustment of the constituents of the milk and the dis- 
appearance of symptoms. 



HABITUAL VOMITING OF INFANTS. 

By habitual vomiting of infants is meant the regurgitation of 
milk in the uncoagulated state shortly after nursing. It occurs in 
infants in apparently good health, and is not followed by loss of 
weight or disturbance in the functions of the gut. Some infants 
vomit curdled milk in the same manner. The cause of this form 
of vomiting has been variously explained. The simplest explanation 
is, that by slight pressure the food is forced into the oesophagus and 
thence reaches the mouth. It is a well-known fact that the stomach 
of the infant can be emptied by gentle abdominal pressure. Another 
explanation is that on deep inspiration the negative pressure caused 
by descent of the diaphragm forces a certain amount of fluid from 
the stomach, which is almost vertical in the infant, into the oesophagus 



HABITUAL VOMITING OF INFANTS. 311 

and thence into the month. This form of vomiting requires no 
treatment. The general impression is that it can be stopped by 
regulating the amount of breast-feeding, but this belief is erroneous, 
as the vomiting persists after such precautions have been adopted. 
Fleischman thinks that the habit is hereditary in certain families. 

There are several other forms of vomiting which are of interest 
in this connection : 

a. Some children vomit when irritated or after outbursts of 
temper, or may vomit at will if their food or anything in con- 
nection with their discipline does not meet their approval. Some 
of the little patients know intuitively that vomiting alarms the 
mother, consequently it will appear whenever any concession is to 
be obtained in the nursery. 

b. Vomiting, especially after eating, may be caused by a severe 
attack of coughing. If vomiting occurs frequently under these con- 
ditions, whooping-cough should be suspected. 

<•. The vomiting of pyloric stenosis of the congenital type is 
characteristic. It is more in the nature of a regurgitation. When 
lying on the back the baby vomits at intervals, and in small quan- 
tities. After a nursing there is an interval, after which the infant 
vomits two or three times the amount of food taken at the recent 
nursing. This is explained by the fact that in this condition there 
is -onie little vomiting constantly going on, due to the increased 
peristalsis of the stomach. There is, however, a small quantity of 
food retained in the stomach. This residual quantity increases with 
each feeding, and is finally rejected in the manner just described. 

d. The vomiting of appendicitis is also characteristic. The patient 
is ~«ized suddenly with sharp abdominal pain and then begins to 
vomit. The vomiting may recur once or twice, and then cease. In 
neglected cases, in the final agonal stage, vomiting due to sepsis and 
toxaemia may be persistent. 

e. Vomiting is the first symptom in intestinal obstruction. It 
may be followed by a very small movement, and then for a short 
time there i-. as a rule, no action on the part of the bowels. The 
vomiting may not recur in the first twenty-four or forty-eight hours, 
except at long interval-, but the bloody movements recur frequently, 
and pain is also present. The vomiting return- when the intussus- 
ception i- more marked, and late in the affection becomes fecal. 

f. Vomiting occurs at the outset of the infectious diseases. Per- 
sistent vomiting extending over a period of months is often of 
nephritic origin. In connection with the subject of constipation, a 
form of vomiting of intestinal toxic origin will be described. 

fj. The vomiting which accompanies meningitis occurs at the out- 
set in that of the cerebrospinal type, and is quickly followed by 
cerebral symptom-. In tuberculous meningitis it occurs at the onsel 



312 DISEASES OF THE G ASTRO-ENTERIC TRACT. 

and after the appearance of a vague series of cerebral symptoms. 
It is rarely persistent after the initial attack. The subsidence of 
the vomiting and the sequence of cerebral symptoms and a febrile 
movement will easily distinguish this form of vomiting from 
others. 

Tumor and abscess of the brain are accompanied by vomiting at 
intervals. 

COLIC. 

Colic is not a disease, but a symptom of disturbed conditions of 
the gut. It is really a painful contraction of the muscle-fibre of 
portions of the gut- wall. In the simplest form the painful contrac- 
tions are incited by actual distention of the lumen of the gut. The 
pain caused in colic is in the majority of cases not of the character 
which arises in certain other affections of the gut which are neurotic 
in nature, nor is it of the same nature as that seen in enteritis. Pain 
similar to that in colic may be caused by the administration of some 
such drug as lead, arsenic, etc. 

Cause. — In the great majority of cases the affection is caused by 
some disturbance of the processes of assimilation in the gut. It is 
uncommon in infants in good condition, and its appearance in any 
case indicates the necessity of an investigation into the condition of 
the digestive processes in the stomach and intestine. The form of 
pain or colic accompanied by distention (tympanites) seen in new- 
born infants, and also at the height of pneumonia in older children, 
has an etiology distinct from that of the ordinary variety. Not 
only is the pain of neurotic origin, but also the distention is a 
result of paralysis of the muscular fibre of the gut. The pro- 
cesses in the gut may be disturbed as a result of the pneu- 
monia. Colic may occur in breast-fed or in artificially fed infants. 
In the former it is not always possible to discover the exact 
cause. The breast milk may be abundant, of good color, and of 
correct composition, and still there may be very violent colicky 
pains. In artificially fed infants the cause of the colic may lie in 
the very nature of the food (cows' milk) and the difficulty of com- 
plete assimilation. Thus not only will an excess of proteids in the 
milk cause colic ; the nature of the proteids of cows' milk, no matter 
how much they are diluted, will cause colic. An attack of colic 
is preceded by general uneasiness ; the infant cries and cannot be 
quieted. The severe colicky pain is accompanied by sharp cries, the 
arms and lower extremities are drawn up, and the abdomen is rigid. 
After the passing of gas the infant is quieted and falls asleep quite 
exhausted. These attacks of colic deprive the infant of sleep ; they 
may or may not be accompanied by tympanites. The movements 
are rarely normal, or may be normal for some days and then take on 



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HYPERTROPHIC PYLORIC STENOSIS. 313 

a curdy character or become greenish. Sometimes the colicky attacks 
are accompanied by a mild form of diarrhoea ; the pain may be so 
severe as to cause convulsions. 



TYMPANITES. 

Tympanites is a condition of distention of the gut with gas, which 
may supervene in inflammatory states of the peritoneum. In such 
conditions (peritonitis, appendicitis) the paralysis of the muscular 
wall of the gut is the real cause of the distention. In other states, 
such as pneumonia, it may be the result of inefficient action of the 
diaphragm and of an enteric catarrh which sometimes accompanies 
that disease. In the newborn infant, tympanites is a result of an in- 
herent muscular weakness of the intestinal Avail (Plate XVI.). In 
colic due to imperfect assimilative processes in the gut, the tympan- 
ites is due to the formation of gases of which the intestine is unable 
to rid itself rapidly. 

In pneumonia the tympanitic distention is sometimes extreme, 
causes great distress, and is frequently mistaken for peritonitis. In 
the forms of distention in the newborn infant the distress is not so 
great. In rachitis there is a state of tympanitic distention of the 
abdomen due not only to defective assimilative processes, but also to 
a lax condition of the muscle-fibre of the intestinal walls. 

Treatment of Colic and Tympanites. — If the food of a bottle- 
fed infant is at fault, the modification of milk must be altered so 
that the proportion of the proteids may be lower. A reduction of 
proteid will not always remedy the condition ; the proportion of 
sugar is sometimes at fault, especially in infants fed on condensed 
milk. Not more than 6 per cent, of sugar should be added to any 
milk modification. Some infants can take a large quantity of malt- 
sugar in their food and not suffer from colic. If a breast-fed infant 
suffers from colic, the hygiene of the nurse should be attended to. 
If after the taking of exercise and regulation of diet the colic persisN 
and becomes a feature in the case, the wet-nurse should be changed. 

The attack of colic is best combated by giving the infant an enema. 
In some cases a -mall amount of dilute hydrochloric acid and pepsin 
given three time- daily will alleviate the symptoms. If in spite 
of all efforts an artificially fed baby suffers with colic and does not 
increase regularly in weight, it should be placed at the breast. 

HYPERTROPHIC PYLORIC STENOSIS. 

{Congenital Stenosis of the Pylorus; Congenital Hypertrophy of the Pylorus and Stomach- 
wall; Congenital Gastric Spam 

Hypertrophic pyloric stenosis is a congenital condition appearing 

from a few day- t«» several week- (three months) after birth, and 



314 DISEASES OF THE G ASTRO-ENTERIC TRACT. 

manifesting itself in persistent vomiting. In a few instanees several 
infants in the same family have been thus affected. 

The etiology of the affection is obscure. Since in the majority 
of the cases which have been carefully studied the infants were over- 
fed or improperly fed, it is supposed that some irritant to the stomach 
is the exciting cause. Thomson, who has made careful studies of 
these cases, believes that the condition originates in intra-uterine 
life, and is due to the ingestion of liquor amuii. This fluid, by 
irritating the mucous membrane of the stomach, excites both that 
organ and the pylorus to overaction. Pfaundler, voicing the teach- 
ings of Escherich's school, denies that there is a true hypertrophy 
of the pylorus, and asserts that the condition during life is that of 
functional spasm. The post-mortem condition is due to toxic 
agonal contracture of the pylorus. 

Morbid Anatomy. — The stomach and oesophagus have been 
found to be dilated in fully one-third of the reported cases. The 
mucous membrane shows the usual changes, such as the congestion 
which is seen in a stomach in which there have been functional dis- 
turbances. The mucous membrane of the pylorus is thrown into 
voluminous folds. The lumen has in some cases been found patent 
to a small probe, but fluids cannot be forced from the stomach into 
the pylorus (Thomson). The muscular fibres show characteristic 
change. The circular fibres are thickened and hypertrophied 
(Thomson). In Finkel stein's case the longitudinal fibres were also 
thus affected. 

Symptoms. — Infants in whom this condition is present are of 
normal weight and appearance when born. As a rule, the desire for 
food is greater than is normal. In the majority of cases the infants 
are allowed, on account of supposed insufficiency of the breast milk, 
to nurse an excessive length of time. It is soon noticed that there 
is vomiting of small quantities of milk after each nursing. After a 
few days all the food taken into the stomach is rejected, and the 
vomiting attacks increase in frequency. The vomited matter never 
contains bile-stained matter. At times it is less than or about 
equal in amount to the quantities ingested at the nursing. At in- 
tervals attacks of vomiting occur during which more food is rejected 
than has been taken at the preceding nursing. This proves that 
there is not only retention of food, but also lack of absorption by 
the mucous membrane of the stomach. 

The infants rapidly lose weight ; the abdomen has a character- 
istic appearance in all the cases I have met. The abdominal walls 
are lax, the coils of gut can be clearly made out, and the peris- 
taltic movements are visible. In the epigastrium, just beneath 
the ribs, is a large coil, and to the right of this a constricting band 
and what appears to be another coil. These are in constant peris- 
talsis. I have seen these coils in two cases, and in both they had 



HYPERTROPHIC PYLORIC STENOSIS. 315 

been mistaken for the stomach. They were, in my opinion, coils of 
the transverse colon. [n two of my cases I could on dec]) palpation 
in the median line, midway between the ensiform cartilage and the 
umbilicus, feel a resistant nodular mass, which may have ben the 
contracted pylorus (Thomson and Finkelstein). I have not been 
able to map out a dilated stomach. 

Prognosis. — If the vomiting is unrelieved, death occurs in from 
three weeks to six months. On the other hand, all of these cases 
are not hopeless. Heubner has seen three cases (Finkelstein) which 
recovered. I have seen three cases in which the history, symptoms, 
and physical signs were undoubtedly those of congenital stenosis, 
and all of which recovered. One case gained to a remarkable degree 
in weight, another in three months contracted gastro-enteritis and 
subsequently a terminal intussusception and died unrelieved ; the 
third recovered. 

Treatment. — All mouth-feeding should be suspended. The in- 
fant is kept in the recumbent position, and the stomach washed out 
once; all binders and constricting clothing are removed from the 
abdomen. The infant is then fed by the rectum for one or more 
days with small quantities of album in- water, or an ounce of 
somatose solution is introduced per rectum three or four times daily. 
This amount, although seemingly small, will if retained, sufficiently 
nourish the patient. The stomach is thus given complete rest. After 
two days teaspoonful doses of albumin-water are given by mouth 
every hour, and are supplemented by rectal enemata. If the vomit- 
ing has diminished or ceased, artificially fed infants are given by 
mouth a very dilute milk modification (0.5 of proteids, '2 of fat) in 
half-ounce doses, pasteurized or sterilized. The milk is given alter- 
nately with albumin-water. Milk is at first given only three times 
in the twenty-four hours alternately with albumin- water. If vomit- 
ing recurs, mouth-feeding is again suspended and rectal alimentation 
substituted. The infant i< not moved, especially after being fed. 
In this tentative way, gradually increasing the quantity and strength 
of the milk (1.2 of proteids, 2.5 of fat), I have succeeded in three 
cases in effecting tolerance of food and cessation of vomiting. 

Medicines arc of little value in these cases. I have used -mall 
doses of bismuth subnitrate in combination with pepsin, to allay 
the irritability of the stomach. 

Surgical Treatment. — Two surgical procedures have been proposed 
and attempted in these cases. The first method is that of opening 
the abdomen and establishing a communication between the stomach 
and gut by means of a Murphy button. This procedure, first sug- 
gested by Schwyzer, was carried out by Willy Meyer on the case 
of Meltzer, with fatal results. The second method is that adopted 
by Nicoll in the case of Ritchie. The abdomen was opened, an 
incision made near the pyloric end of the stomach, the pylorus 



316 DISEASES OF THE G ASTRO-ENTERIC TRACT. 

forcibly dilated with forceps, and the wound closed. The infant 
recovered. This latter is the only recorded case of recovery after 
operation. In view of this fact, I believe that with these weak 
infants every expedient should be tried before resorting to surgical 
intervention. 

ACUTE GASTROENTERITIS 

(including Cholera Infantum). 

(Summer Diarrhoea; Acute Gastro-enteric Infection.) 

Acute gastro-enteritis is a form of diarrhoea usually accompanied 
by gastric symptoms. It is prevalent in the summer, but may also 
occur during the winter months. Bottle-fed infants are more subject 
to the affection, although it occasionally attacks infants at the breast. 
In institutions epidemics of gastro-enteritis occur in breast-fed in- 
fants. In large cities more than one-half the deaths among infants 
under the age of twelve months are caused by summer diarrhoea. 
In Paris, Chaterinkoff found that of 20,000 children dying of 
gastro-intestinal disorders, fully three-fifths were bottle-fed. This 
high rate of the mortality of bottle-fed infants, as compared with 
that of breast-fed infants, is not alone due to the difference in the 
nature of the food ; no matter how carefully it is handled before it 
reaches the infant, milk passes through many channels, and in each 
of these it is exposed to infection. The intense heat of summer 
also favors the increase of infectious agents. 

Classification. — The various forms of acute gastro-intestinal in- 
fection may be divided into those whose source of infection lies out- 
side the body (ectogenous) and those in which the elements of 
infection are pre-existent in the body (endogenous). This classi- 
fication (Escherich) of the diarrhoea of infancy is both practical and 
in accordance with the results of recent study. In the first class 
are included the diarrhoeas of toxic origin and cholera infantum ; in 
the second are included the diarrhoeas which are caused by varieties 
of bacteria pre-existent in the gut, but which, in the opinion of 
Booker, Escherich, and Marfan, may under favorable conditions 
increase to enormous numbers and become virulent, According to 
Booker, no one specific micro-organism is the essential cause of 
ga.-tro-enteritis or acute summer diarrhoea. Escherich has shown 
that the coli group may under certain conditions become virulent. 
Of the bacteria which are found in certain forms of gastro-enteritis, 
the Streptococcus enteritidis seems to have attracted the greatest at- 
tention. Booker first insisted on the importance and peculiar role of 
this micro-organism. He found these streptococci in great numbers 
not only in the stools of infants suffering from acute summer 
diarrhoea, but also in the walls of the gut and in the various organs 



ACUTE G ASTRO-ENTERITIS. 317 

of the body. Escherich, Libman, and Hirsch have confirmed tlie 
results of Booker. Escherich regards the Streptococcus enteritidis as 
an ectogenous infection. The udder of the cow may be the source 
of this micro-organism. Marian and Booker are also inclined to 
believe that streptococci are able under certain conditions to increase 
in number and virulence and that they are one of the endogenous 
forms of infection by a micro-organism normally present in the gut. 
Among the other bacteria found in enormous numbers in the move- 
ments of infants and children suffering from acute gastroenteritis 
are the Bacillus pyocyaneus (Kossel and Baginsky), Proteus vul- 
garus (found by Booker in choleriform diarrhoea), and the proteolytic 
bacteria, or the ferment of the casein of the milk. The last class 
comprises peptonizing bacteria, such as the Bacillus subtilus, Bacil- 
lus mesentericus vulgatus, and Tyrotrix tenuis. These peptoniz- 
ing bacteria are not found in the gut or stools of the breast-fed 
infant either when in good health or sick. AVe may thus classify all 
diarrhoeas of acute gastro-enteritis as follows : 

1. Those due to improper food, or the so-called mechanical irrita- 
tive diarrhoeas (Booker). 

2. The infectious form of gastro-enteritis (endogenous and ecto- 
genous). This class would include the toxic diarrhoeas of some 
authors. 

Xot only the food and the bacteria, but also certain changes in 
the gut play an important role in acute gastro-enteritis. 

Morbid Anatomy — Stomach and Intestines. — Booker has 
described a superficial loss of the epithelium of the stomach and gut, 
as a constant lesion in all fatal cases of gastro-enteritis. It may be 
intact in some places and destroyed or eroded in others. The 
mucous membrane of the jejunum and duodenum may show less 
denudation than other parts of the gut. The epithelial layer 
of the mucosa is infiltrated with leucocytes in diffuse areas or nests. 
The infiltration may push the epithelial layer upward. The mucosa 
itself is infiltrated with poly nuclear and mononuclear leucocytes to a 
varying extent. The mucosa shows superficial or deep ulcerations 
involving the crypts or villi. Heubner has described a form of 
necrosis which chiefly affects the epithelial structure without involv- 
ing the deej) mucosa. This occurs in cholera infantum. Booker 
also describes a bronchitis and a form of bronchopneumonia which 
are quite constantly found in fatal cases of gastro-enteritis. Hem- 
orrhages into the lung tissue are common. 

In the kidneys there is necrosis of epithelium in the convoluted 
and irregular tubules (Booker). 

The liver shows fatty degeneration and necrosis of the liver-cells. 

The lymph-nodes show focal necrosis. 

The Role of the Bacteria. — Booker has demonstrated that no 
bacteria are found in the mucosa of the intestine if the superficial 



318 DISEASES OF THE GASTROENTERIC TRACT. 

epithelium is intact. If there is a lesion of continuity of the super- 
ficial layer, the bacteria invade the mucosa in large numbers. There 
is reason to believe that the toxins generated by the bacteria in the 
gut cause the superficial erosions and prepare the way for invasion 
of the lymph-channels and bloodvessels. Bacteria are not always 
found in the lesions, but as a rule the ulcerations of the mucosa 
show vast numbers. Booker found bacteria in cultures taken from 
the solid organs and blood, thus confirming what Czerny and Mozer 
found to be the case during life. The lungs especially showed large 
numbers of bacilli and cocci. 

Symptoms — In the mild form of gastro-enteritis the infant is 
restless and cries at intervals because of colicky pains. It may pre- 
viously have been in good health, but with the advance of these symp- 
toms there will also be noticed a slight febrile movement and a disin- 
clination to take the bottle or breast. Vomiting occurs after feeding, 
the rejected contents of the stomach being curdled and having a 
marked acid odor. In mild cases the vomiting is usually not severe. 
It may be repeated three or four times in the twenty-four hours. 
The movements are at first normal ; they afterward become frequent 
and contain whitish curds or greenish and white curds, are more fluid 
than is normal, and may have a very offensive odor. In mild cases 
there may be only two or three such movements in the twenty -four 
hours or they may number six or more. Later, the fever also 
becomes more marked, the temperature sometimes mounting as high 
as 103° F. (39.4° C). If the feeding is continued, the vomiting 
persists. The infant shows little or no prostration. 

In severe cases the vomiting is marked from the outset. The 
infant not only vomits its regular food, but will also often vomit all 
fluid that is taken into the stomach. The diarrhoea is also more 
severe than in the mild forms. The movements are at first yellow 
or greenish and contain white curds, but as the disease advances 
they become more fluid, until in very severe cases only a greenish 
malodorous liquid containing small particles of mucus and fecal 
matter is voided. The infant has a febrile movement which varies 
from 101° to 103° F. (38.8° to 39.4° C), and there is marked 
prostration. In the acute forms of gastro-enteritis there is con- 
siderable loss of weight ; the infant becomes pale and languid, and 
the pulse is rapid and weak ; the number of daily evacuations may 
reach twenty. In some cases the straining causes a descent of the 
lower part of the rectum, and the movements contain a slight 
amount of bloody mucus. The odor of the evacuation may not 
be offensive. If the patient improves, the symptoms retrograde 
— the vomiting becomes less frequent, the stools more fecal in char- 
acter and less numerous, and the fever subsides. If, on the other 
hand, the symptoms progress, the movements not only continue fre- 
quent and fluid, but also blood and particles of mucus are mingled 



CHOLERA INFANTUM. 319 

with the fecal matter. The vomiting may cease entirely. The in- 
fant loses in weight steadily ; the movements are small and passed 
with tenesmus ; the patient passes into the subacute stage of gastro- 
enteritis. In some cases there i> colic ; the infants are restless or 
pa-- into an apathetic condition. Little urine is passed, and in the 
majority of eases of mild or severe gastro-enteritis, albumin is 
present. It rarely amounts to more than a trace. In severe cases 
there are leucocytes and epithelial, hyaline, and blood-casts in the 
urine ; sometimes in addition a few blood-cells are found. 

In the subacute forms of gastro-enteritis which last for more 
than a week, bronchopneumonia may be a complication. This form 
of bronchopneumonia is described in the section on Pneumonia. In 
some case- it is of short duration, in others persistent. Broncho- 
pneumonia with slowly resolving areas of consolidation in the lung 
is the type met with. 

Course and Prognosis. — The prognosis of the mild forms of 
gastro-enteritis is good, if proper measures are adopted. The severe 
forms are exceedingly fatal in summer. The mortality varies with the 
environment. In the crowded tenements of large cities and in un- 
hygienic surroundings the mortality is great, as is also the case in 
institutions and hospitals. In private practice the isolation of the 
patient and special nursing reduce the mortality to a minimum by 
preventing reinfection. Reinfection is caused by lack of care in 
handling the diapers and in preparing the food, by giving improper 
food, and by placing a number of eases in the same room. There 
can be no question that in hospitals patients are affected unfavorably 
by proximity to other patients suffering with the same disease. Xo 
matter how careful the nursing under such circumstances, reinfection 
cannot be prevented. Also, perfect cleanliness is not so nearly at- 
tainable in hospitals as in private practice. 

Cholera Infantum. 

Cholera infantum is the severest form of summer diarrhoea prev- 
alent among infants. It is believed that it has a specific origin, 
but this has not as yet been demonstrated. Cholera infantum does 
not occur so frequently as has been hitherto supposed. Of hundreds 
of cases of gastro-enteritis of the acute variety which come under 
my care yearly, only a few can be called typical of this form of 
infection- diarrhoea. These cases occur for the most part in weakly 
bottle-fed infants. Breast-fed infants may occasionally be affected, 
especially in hospitals. 

Symptoms. — The infants as a rule have been suffering from a 
mild diarrhoea. Following a slight febrile movement, vomiting and 
diarrhoea of a severe and exhausting character set in. The bowel 
movements are frequent, but contain very little fecal matter after the 



320 DISEASES OF THE GASTBO-ENTERIC TRACT. 

first few have been passed. They are at first greenish, afterward 
becoming watery, resembling barley-water; they contain but a few 
flocculi of mucus, and may not have much odor. The vomiting is 
incessant. First the stomach contents are vomited, and finally a 
greenish fluid. Within a few hours the infant is reduced to a con- 
dition of great prostration. The loss of weight is marked, even in 
the first twenty-four hours. The skin on the thighs is wrinkled. 

The face and trunk are pale and the face is drawn. There is 
fever to a marked degree (101°-103° F., 38.3°-39.4° C), and 
the pulse is rapid and thready. Toward the close the movements 
are passed involuntarily. The whole picture is that of a choleriform 
disease. As the fatal issue approaches the eyes become sunken and 
glassy, the fontanelle is depressed, and the mouth is open. The con- 
dition described elsewhere as hydrencephaloid sets in. Convulsions 
and a rise of temperature (105° to 107° F., 40.5° to 41.6° C.) 
precede the fatal issue. 

Occurrence. — These severe choleriform diarrhoeas resemble Asiatic 
cholera very closely, and should be sharply differentiated from severe 
forms of gastro-enteritis. They occur in bottle-fed infants under 
the age of two years, and chiefly in the months of July and August. 
Heat and infected food are the main etiological factors. A diarrhoea 
of a mild type is the forerunner in the majority of cases. These 
cases are not so frequent to-day as they were in the days when 
infants were fed with decomposed milk containing bacterial toxins. 
This form of diarrhoea must therefore be looked upon as a purely 
ectogenous infection. 

Duration and Prognosis. — The prognosis in the majority of 
cases of cholera infantum is grave. The disease is an exceed- 
ingly fatal one, occurring as it does for the most part in infants fed 
on the bottle and whose general condition is poor. It lasts for from 
twenty-four hours to two or three days. The rapidity of the devel- 
opment of the symptoms and of the fatal results precludes the possi- 
bility of any complications other than those due to the great drain 
on the system. The condition of hydrencephaloid is hardly a 
complication ; it is a terminal set of cerebral symptoms. Sclerema, 
mentioned by some authors, I have not met in true cholera infantum ; 
it is seen in the terminal stage of acute forms of gastro-enteritis. 
This form of sclerema affects the thighs at the upper and inner 
part. It is described in the section devoted to that subject. 

Kjelberg, Felsenthal, Bernard, Morse, and the author, found 
albumin and casts in the urine of children suffering from all forms 
of gastro-enteritis, acute and subacute, including cholera infantum. 

Morse as w T ell as the author found that the urine was concentrated 
and contained hyaline, granular, and epithelial casts, with leucocytes 
and blood and blood-casts. The albumin is rarely present to a 
marked degree. It is a trace or a distinct reaction. The urine is 



CHOLERA INFANTUM. 321 

suppressed in severe cases, and lessened in quantity in others. In 
some eases of gastroenteritis of the severe types there is slight 
(edema of the subcutaneous tissues, especially on the inner part of the 
thighs, the legs, and dorsum of the foot. We are not in a position 
to trace any close relationship between the general symptoms and 
the disturbances of the kidney. The toxaemia in this disease, caus- 
ing as it does vomiting and nervous symptoms, masks the nephritic 
symptoms if they are present. 

The diagnosis of acute gastro-enteritis is not difficult. There 
are. however, many infectious diseases, the onset of which closely 
resembles that of an attack of gastro-enteritis. Scarlet fever, for 
example, begins with vomiting, and in some cases with diarrhoea. 
There is a form of grippe which in its onset, with vomiting and 
diarrhoea, closely resembles an attack of gastro-enteric disease. In 
fact, these symptoms may persist in the course of the former affec- 
tion. 

The physician should not be satisfied with a history of gastro- 
enteric symptoms, but should carefully examine the skin, throat, 
and chest at every visit. In the severer forms of diarrhoea a small 
particle of the movement may be spread on a cover-glass and ex- 
amined for an excessive number of streptococci. In mild forms of 
diarrhoea we should not fail to make a Widal test of the blood and a 
count of the leucocytes, to eliminate the possibility of typhoid fever. 
This will especially be indicated in cases in which there is enlarge- 
ment of the spleen. 

Treatment of Acute Gastro-enteritis and Cholera Infantum. — 
Prophylaxis. — The nursing bottles when emptied by the infant 
should be filled with a saturated solution of sodium bicarbonate, 
allowed to stand for a few hours, and then carefully washed inside 
and out with a bristle brush. The nipples should be sterilized daily. 
The nurse or mother, after attending to the diapers of the infant, 
should carefully cleanse the hands before feeding the baby. The 
milk should be diluted as directed in the section on Infant Feed- 
ing, pasteurized or sterilized, and then kept on ice until needed. It 
should be obtained from a dairy in which cleanliness of the utensils 
and in the milking of the cows is observed in all details. The milk 
should be fresh and delivered for modification within a few hours 
of the milking-time. The nursings should be conducted at stated 
intervals. If there is a residue in the nursing bottle, it should not 
be utilized for a subsequent nursing. The infant is given a full 
bath daily. By attending to all these details, infection of the food 
and of the infant may be avoided. With breast-fed infants prophy- 
laxis IS of great importance. A baby at the breast should be i'vd 
at regular interval-, 'flic breast-nipples should be washed with a 
saturated solution of boric acid before and after nursing. The baby 
should not be allowed to nurse a breast with a fissured nipple. 
21 



322 DISEASES OF THE G ASTRO-ENTERIC TRACT. 

The milk of such a breast is pumped off, and au attempt is made 
to heal the nipple in the manner elsewhere described. If there is 
caking of the breast, the condition should be remedied before the 
infant is allowed to nurse. Abundance of fresh air and bathing are 
indicated in these infants as in bottle-fed infants. 

Sick Infants. — As soon as a baby shows signs of even mild dys- 
pepsia or gastro-enteritis the milk should be discontinued, a simple 
cathartic given, and the infant kept for twenty-four hours on a 
solution of egg-albumin. Vomiting which has occurred only once 
or twice does not call for active treatment, as it will disappear as 
soon as the milk is discontinued. After the bowels have moved, if 
the infant shows no exacerbation of symptoms feeding should be 
resumed cautiously. In this way a severe gastro-enteritis can be 
averted. If the food is not suitable, causing signs of dyspepsia 
such as colic, it should be changed if possible, else severer symptoms 
may result. If in spite of all precautions an attack of gastro- 
enteritis develops, the patient should be treated on the following 
lines : 

1. The food is stopped and another of a safe character substi- 
tuted. 

2. The toxins are eliminated and the strength of the patient 
supported by the so-called mechanical methods. 

3. Drugs are used to abate the symptoms and support the 
strength of the patient. 

The milk, whether of the breast or bottle, is discontinued. The 
infant is given a solution of album in- water, acorn-cocoa, or beef- 
juice expressed and diluted with barley-water. A baby can be kept 
for days upon these mixtures without any danger of reducing the 
strength. The white of one egg is equal in nutritive value to three 
ounces of breast-milk. It is digestible, and is well borne by infants. 
Album in- water may be used alternately with the solution of acorn- 
cocoa or beef-juice and barley-water. To older children who are 
suffering from gastro-enteritis we may sometimes have difficulty in 
administering albumin- water or acorn-cocoa. Under such conditions 
I frequently resort to a dextrinized gruel or the so-called Liebig's 
soup mixture which Keller advised. I find that after the acute 
symptoms are past, infants and children who refuse every other form 
of food will take this with eagerness. It may be given while the 
diarrhoea is still in progress, but should not be given until the vom- 
iting has ceased. 

The cathartic given at the onset should be castor oil or calomel, 
grain ss (0.03) doses twice or three times a day. Infants who are 
vomiting are given calomel in preference to castor oil. 

The Vomiting. — If the vomiting is not severe and the case is 
under treatment from the onset, it is best not to wash out the 
stomach at once. It often happens that the vomiting ceases as soon 



CHOLERA INFANTUM. 323 

as the regular food is stopped. If, however, the vomiting persists 
for twenty-tour hours, we proceed to wash out the stomach once. 
It' the vomiting continues after this, it is either toxic or may in 
rare eases be due to sonic other causes. As a rule, it ceases after 
one irrigation of the stomach. 

The diarrhoea is controlled by irrigation of the gut. The rectum 
and gut are washed out in those cases in which the diarrhoea is not 
only persistent, but progressive. Tha object in washing out the 
lower bowel in any form of acute gastro-enteritis is twofold : («) 
to remove any residue of feces that may have collected in the lower 
bowel and rectum, and to stimulate peristalsis and thereby favor 
evacuation from above ; (b) to stimulate the heart and add to the 
body an amount of normal solution to compensate for the drain 
caused by the diarrhoea. The Cantani normal salt solution is 
utilized in the manner described on page 42. 

The rectal enemata are given under a pressure obtained by an 
elevation of at most two feet from the bed. A temperature of 107° 
to 110° F. (40.5° to 43.3° C.) is the best and most stimulating in 
these cases. Fully a quart of water is thrown into the rectum in 
half-pint portions. As the half-pint flows in, the funnel on the 
rectal tube is disconnected and the contents of the bowel are allowed 
to escape. Another portion is then allowed to flow into the bowel. 
The water will sometimes escape alongside of the tube. This is 
rather a favorable sign, being significant of the contractile powers 
of the gut and abdominal walls. Only two enemata daily are neces- 
sary, even in severe cases of acute gastro-enteritis. As the diarrhoea 
and symptoms subside we reduce the number of enemata to one, 
finally discontinuing them entirely as the infant improves. It 
sometimes happens that after a few days the enemata are followed 
by movements containing blood and mucus, the tenesmus being 
aggravated. In these exceptional cases an enema must be given 
only every other day, and the effect on the rectal discharges watched. 
By stopping the enemata altogether it can be determined whether 
the discharges of mucus and blood are caused by the therapy or the 
disease. 

Hypodermoclysis. — The injection of normal salt solution under 
the skin i< indicated only in the severe eases of aente gastro- 
enteritis in which, as in cholera infantum, the course of the disease 
is rapid and the prostration extreme. Personal experience rather 
discourages the employment of large injections by this method. I 
have seen two cases of infection by the Bacillus capsulatus aero- 
gene^ (Welch) following hypodermoclysis. These occurred through 
the use of saline solution evidently insufficiently sterilized, and 
which had probably been allowed to stand before being u<vd. In 
a third case hemorrhages over large areas occurred at the point of 
the injection of the salt solution. These injections an; also very 



324 DISEASES OF THE GASTRO-ENTERIC TRACT. 

painful. Because of these clangers and disadvantages the subcuta- 
neous injections of salt solutions should be utilized as a last resource 
in desperate cases. Small rather than large amounts of fluid should 
be injected subcutaneously, as was advised on page 36. The salt 
solution for the hypodermoclysis is that of Cantani. It should be 
sterilized at a temperature of 212° F. (100° C.) for at least an 
hour, to kill sporulated bacteria if possible. A very fine hypodermic 
needle is used in the manner described on page 36. 

Baths. — In all cases of acute gastro-enteritis, whether with or 
without elevation of temperature, the benefit obtained from warm 
baths cannot be overestimated. In cases of great prostration a bath 
of 108° F. (42.2° C.) for five minutes is stimulating to the nervous 
centres and is followed in many cases by diminution of the apathy 
and an apparent reduction of the effects of toxaemia. If the tem- 
perature rises above 103° F. (39.4° C), sponging with water at 
80°-85° F. (26.6°-29.4° C.) is all that is needed. This should 
not be done oftener than once in every three hours. 

Alcohol. — Of late years, whiskey is given less and less in cases 
of acute gastro-enteritis. In these cases there is a special intoler- 
ance of the stomach and also of the economy to whiskey. Infants 
after taking it for twenty-four hours will become stupid, apathetic, 
and exhibit a constant retching if they do not vomit. This appears 
to be due more to the effect of the alcohol locally on the stomach 
and also systemically than to toxaemia of the disease. I therefore 
deprecate the use of alcohol except in extreme cases, when whiskey 
is given in small doses at short intervals. 

Strychnine is useful for its stimulating effect on the heart. Grain 
-3^-q- (0.0002) is given to an infant of six months, and grain -^^ 
(0.0003) to older infants every three hours. 

Atropine, lately advised as a cardiac stimulant in these cases, 
especially in cholera infantum, is a dangerous drug, and should not 
be employed. I have seen grain yi-g- (0.0004) give rise to constant 
tremulous and convulsive twitching. 

Resorcin. — If the vomiting is constant, grain J (0.008) of 
resorcin given every three hours is a safe and very useful remedy. 
It should never be used in larger doses nor at shorter intervals. 

Bismuth in the form of the subcarbonate is the only drug useful 
in allaying the vomiting and the tenesmus of the bowel. Grains ij or 
iij (0.12 or 0.18) are given in powder form every two or three hours. 

Opium in any form has fallen into disuse. In the severe cases it 
is dangerous, and may increase the prostration ; in the milder cases 
its use is justifiable only if the colicky pains are excessive. The 
milder preparations such as the wine and the camphorated tincture 
are of value, because they can be given in graduated doses, and the 
effects determined more exactly than can be done with the stronger 
preparations. 



GASTEO-iyTESTINAL ATROPHY. 325 

Salol in grain J (0.03) doses every three hours may be combined 
with the bismuth to allay the colicky pains. 

Tannigen is a useful drug in the chronic forms of intestinal dis- 
ease, but an irritant in the acute forms. 

Colic has been mentioned so often that a few words as to the 
treatment may not be out of place. Passing of the rectal tube rarely 
relieves it. A small rectal enema has been found to be a very 
effective remedy. 

As the symptoms improve care should be taken not to return to 
a milk diet too quickly. The milk is given in dilutions and is 
sterilized carefully. Infants in an enfeebled condition as a rule 
bear this form of milk best, since it is not apt to be irritating to the 
gut. When the danger is past any form of milk may be given — 
raw, pasteurized, or sterilized — care being taken that all the pre- 
cautions as to freshness, cleanliness, and proper preparation are 
observed. I have mentioned the fact that before returning to 
dilutions of milk the exhibition of dextrinized gruels has been suc- 
cessful with very weak infants. The malt, the cereal, and the milk 
acted upon by the ferment contained in these mixtures are all easily 
digestible and assimilable, and promote increase of weight. As a 
matter of course, the effect of the gruel mixture on the stomach and 
gut should be carefully studied. 

Whatever methods are employed in the treatment of acute gastro- 
enteritis, it is necessary to avoid the error of overtreatment. It 
should be remembered that hours of rest do more than hours of 
treatment. Three-hour intervals should elapse between the appli- 
cation of remedial measures. Fresh air in the room or a sojourn 
of a few hours in the open with absolute quiet, is of the greatest 
value in these cases. 



GASTROINTESTINAL ATROPHY. 

[Marasmus; Athrepsia (Parrot); Simple Infantile Atrophy; Chronic Gastrointestinal 

Catarrh.) 

Atrophy may follow or complicate congenital syphilis or any 
subacute or chronic disease of the gut. Gastro-intestinal atrophy, 
or the athrepsia of Parrot, is a condition due to a faulty operation 
of the assimilative processes in the gut. 

The etiology of chronic atrophy is unknown. Keller, who lias 
studied this condition extensively, believes that in infant- and 
children suffering from gastro-enteric catarrh there is an excessive 
production in the gut of acids which under normal conditions arc 
neutralized. Tn disturbed conditions, instead of urea, ammonia is 
excreted in the urine. The formation of the ammonia entails a 
drain on the economy — hence the emaciation. Excess of album i- 



326 DISEASES OF THE GASTRO-EXTERIC TRACT. 

noids and fats in the food favors overproduction of acids in the gut. 
In marasmus there is an acid intoxication of the economy, origi- 
nating in the gut. There is no doubt that under unhygienic con- 
ditions and in overcrowded hospitals infection of one patient by 
another may take place. No satisfactory explanation of the manner 
in which such infection occurs has as yet been advanced. Heubner 
has surmised that the excreta of one patient in some way contami- 
nates the food of another by transmission through the nursing per- 
sonnel. This is true in a certain number of cases, but not in all. 
Cases of marasmus seen in private practice show progressive emacia- 
tion in spite of the fact that the utmost care is exercised in the 
preparation of food and the strict maintenance of hygienic condi- 
tions. 

Morbid Anatomy. — The body is much emaciated; the skin 
hangs in folds on the extremities, and presents hemorrhages and 
petechia. The lungs may show atelectatic areas or may be the 
seat of bronchopneumonia. The heart is small and the muscle- 
fibre pale. In many cases the stomach is dilated and the mucous 
membrane pale. The small intestine shows few changes. The 
Peyer's patches may be slightly raised and show the so-called shaven- 
beard appearance. The follicles of the colon may be slightly prom- 
inent. The microscopical changes in the gut are characteristic. In 
some places the follicles are the seat of catarrhal inflammation. 
Both in the stomach and the intestines there are patches where there 
is an absence of glandular tissue ; in its place is a newly formed 
connective tissue composed of round and spindle-shaped cells. The 
villi of the gut have disappeared. The whole mucosa is thinner 
than is normal (Baginsky). On the other hand, these changes may 
not be marked. The liver is fatty and may be enlarged. The 
spleen is small. The kidneys may be pale, especially in the cortex, 
and may be the seat of parenchymatous degeneration. The lymph- 
nodes of the mesentery may be enlarged. 

Symptoms. — Cases of gastro-mtestinal atrophy are seen among 
the better classes, but, as a rule, they form a large contingent of 
dispensary cases exposed to unhygienic surroundings, and often im- 
properly fed. The infant may have been small at birth or prema- 
turely born. In some cases, especially in families in good circum- 
stances, the baby may have been put at the breast and have done 
well up to the time when, for some reason, it was put on condensed 
milk or milk which had been carefully modified. In other cases the 
infant may from the outset have been fed on the bottle with good 
results up to a certain point, when the weight became stationary and 
the infant retrograded and showed signs of atrophy. The atrophic 
course having once begun, the symptoms vary little. There is no 
gain in weight. The skin, especially about the inner parts of the 
thighs, becomes wrinkled, and the subcutaneous adipose tissue 



GASTRO-IXTFSTIXAL ATROPHY. 327 

diminishes in amount. The extremities lose their normal plump- 
ness. The face has a pinched appearance. The chest is emaciated 
and the ribs show plainly. The fontanelles, if still open, may he 
somewhat depressed. Over the buccinator muscles is seen a small 
cushion of fat, the so-called " sucking pads," which remains when 
all the other fat has disappeared. This gives to the face a peculiar 
appearance that i- typical of cases of atrophy. If the infant is not 
well taken care of, erosions and aphthae are seen on the mucous mem- 
brane of the mouth and gums, and there may also be sprue. Even 
in well-cared-for infants the buttocks may be slightly eroded. If 
the infant has been neglected, there is marked intertrigo. The but- 
tocks are emaciated and the tuber ischii show prominently. During 
the progressive emaciation the infants have constant gastro-enteric 
disturbances. There are colic and at times constipation, or diarrheal 
movements alternating with constipation. The movements of the 
same infant vary greatly. They may be greenish with white curds, 
arc sometimes exceedingly offensive, and at other times may be 
normal and alternate with slightly diarrheal movements. The tem- 
perature is normal or slightly subnormal. During exacerbations of 
the intestinal disturbances, it may rise slightly. These disturbances 
of the gut do not seem to be influenced by changes in the diet. The 
infants in many cases finally lose all desire for food. Others drink 
with avidity, but do not assimilate the food taken. If untreated, 
these infants emaciate until they are reduced to skin and bone. 
Thev grow exceedinglv weak, and die with some intercurrent infec- 
tion, such as pneumonia, tuberculosis, or infectious disease. 

Treatment. — If an infant suffering with chronic atrophy comes 
under treatment at from the third to the fifth month, the proper pro- 
cedure is to place it on good breast milk. If this is not feasible and 
the bottle is the only resort, the task is more difficult. In rare cases 
carefully modified cow-' milk (with the formula of proteids, 1.2; 
fat, 2.5; sugar. 6) will give the desired results if the infant has 
not previously had a correct diet, but has been given a proprietary 
food or a condensed milk formula. In my experience in ambulatory 
cases, no milk formulae of any kind have been universally success- 
ful. I have found that many of these cases if put on a gruel and 
milk diet, according to the method described by Keller, and detailed 
elsewhere in this work, do well : the weight increase-, the colic dis- 
appears, and the character of the stools improves. After the weight 
reaches a certain point the milk gruel is discontinued and the infants 
continue to do well on an ordinary milk formula. In certain cases 
of marantic infant- of the age of twelve months this method has 
been very successful, especially with those whose distaste for the 
ordinary milk food- gradually increased. It is necessary to study 
out the method of feeding which seems likely to be best adapted to 
the individual case. Greater success can be attained in private prac- 



328 DISEASES OF THE G ASTRO-ENTERIC TRACT 

tice than in hospitals. With the feeding, the general hygiene of the 
infant should receive attention. Daily baths with sea-salt and open- 
air life are especially indicated. 

In infantile atrophy the medical and mechanical treatment are of 
less importance than the selection of proper food. For this reason 
we should not seek to multiply remedies. The movements of the 
bowels in some cases have an exceedingly fetid odor. The treatment 
is begun with the administration of brisk cathartics, such as castor 
oil. The bowel is then washed out once a day in the same manner 
as in gastro-enteritis until the character of the movements has 
improved. If there is a tendency to diarrhoea, tannigen, with or 
without bismuth, may be given three or four times daily. If 
there is any great amount of gas generated in the stomach, a very 
small dose of dilute hydrochloric acid and pepsin should be given 
daily after a feeding. 

ACUTE AND SUBACUTE ENTEROCOLITIS. 

(Enteritis Follicularis ; Enteric Catarrh.) 

Enterocolitis is peculiarly a diarrhoeal disease of infancy and 
early childhood. It was formerly classified as a form of dysentery, 
because in these cases the movements are tinged with blood and con- 
tain mucus. The cases are, however, really of a milder type, and 
present many symptoms foreign to true dysentery. 

Etiology. — In many of its features this affection resembles 
acute and subacute gastro-enteritis. It is prevalent during the sum- 
mer months. It occurs in infants after the first year of life, and may 
be primary or follow an ordinary dyspeptic diarrhoea, an exanthema, 
pertussis, or bronchopneumonia. Booker has described the great 
number of streptococci found in certain of these cases. Finkelstein 
and Escherich and his pupils have confirmed these results, and have 
in addition presented the view that these diarrhoeas are infectious, and 
may be caused by bacteria of the coli group. The bacteria may be 
introduced from without, or the coli organism in the gut under cer- 
tain conditions may become virulent. With reference to their origin, 
these cases may be considered as bearing a relationship to cases of 
true dysentery, from which with our present imperfect knowledge 
it is not always possible to distinguish them. 

Morbid Anatomy. — The mucous membrane is hypersemie and 
swollen ; in cases of long duration the mucosa is infiltrated with 
small round cells. The follicles of the gut are enlarged and elevated 
above the surface of the mucous membrane. The Peyer's patches 
are enlarged and surrounded by a zone of hyperemia. The villi 
show desquamated epithelium and infiltration of the walls with 
small round cells. The follicles are swollen, and at the surface may 



DYSENTERY. 329 

hurst and present follicular ulcers. The epithelium of the gut may 
be lacking in places. 

Symptoms. — In the beginning there are fever and slight vomit- 
ing. The movements are fluid, greenish, and have a disagreeable 
odor, contain mucus, and are streaked with blood. They may number 
ten or twelve in twenty-four hours. Straining at times accompanies 
the movement. As a rule the infant is pale and prostrated. The 
character of the movements is unchanged for from a few days to 
two or three weeks, when improvement begins and recovery ensues. 
On the other hand, in protracted cases the infaut may develop a 
bronchopneumonia in one or both lungs, but may even then recover 
under good management. The picture thus resembles that of a mild 
dysentery, but the subjects are younger, and there is in a number 
of cases a history of antecedent intestinal disturbance of extensive 
duration. 

The treatment should be carried out on the same lines as in 
acute gastro-enteritis. Caution should be exercised in returning to 
a diet composed exclusively of milk. While in true dysentery in 
older children I advise the administration of milk sterilized in some 
form, in younger infants such a procedure would be unwise. I 
keep these infants on a diet devoid of milk, such as beef-juice and 
barley-water, albumin-water or solution of acorn-cocoa, as long as 
possible. As the character of the movements improves the infants 
are put on a dilution of albumin-water and milk or cocoa and milk, 
or, what is far preferable, dextrinized gruel and milk. The amount 
of milk in the dextrinized mixture is gradually increased until the 
quantities appropriate to the age of the infant are given. 



DYSENTERY. 

(Ileocolitis ; tbt'itis Contagiosa; Coli Colitis; Enteritis FoJlicularis ; Enterocolitis.) 

Dysentery is an acute infectious diarrhoeal affection of the 
intestine. In the United States it occurs both sporadically and in 
localized epidemics. It is endemic in the tropics, where the etiology 
mewhat different from that in our climate. The protozoon in- 
fection (amoebic) seems, according to Kartullis, to be characteristic 
of the tropical form. Although amoebic dysentery is occasionally 
seen here sporadically and in cases of persons recently returned from 
the tropic-, it is not the form which commonly occurs in infants and 
children. The form to which these patient- are Liable is seen during 
July, August, and September, and [ate in the autumn. It may affect 
nurslings who are fed artificially, but most often occurs in children 
who are on a mixed diet. K.-cherich has described epidemic- of 
limited character in private families and hospitals. I have met this 



330 DISEASES OF THE GASTRO-ENTERIC TRACT. 

form of dysentery in sporadic cases or small local outbreaks, arid 
have also seen outbreaks at seaside resorts among children of from 
two to four years of age who had partaken of drinking-water which 
had been rendered unfit for use by contamination. 

Etiology. — The essential cause of dysentery or ileocolitis is now 
recognized to be bacterial. It is due in certain cases to the intro- 
duction of bacteria of the coli group into the gut from without 
(Escherich). Maggiora, Celli, and others have described coli bacteria 
in the stools in epidemic dysentery. These authors have shown 
that these bacilli, which resemble the Bacterium coli of Escherich, 
may cause hemorrhagic colitis in lower animals. French writers 
think that the coli group existent in the gut may under abnormal 
conditions of intestinal disturbance assume a virulence not normal 
to them. Escherich, on the other hand, has endeavored to show that 
bacteria of the coli group, if introduced into the gut from without, 
either in the drinking-water or in food, may become very virulent. 
Among the other bacteria which have been found in isolated cases 
are forms of streptococci. These were isolated in a very severe 
case of sporadic dysentery in my hospital service. 

Morbid Anatomy. — Dysentery may affect different sections of 
the gut at the same time, the rectal or sigmoid flexure alone, the 
ascending colon, the transverse or the descending colon only. In 
rare cases the disease may pass beyond the ileocecal valve and 
involve the lower part of the ileum. There are two forms which 
may be present separately or simultaneously in the same gut — the 
catarrhal and the necrotic form. 

In the milder catarrhal form of dysentery the mucous membrane 
is hypersemic and swollen, and the summits of the intestinal folds 
are studded with hemorrhages in small foci or streaks. The sub- 
mucosa is infiltrated with small round cells and the vessels filled with 
blood. The epithelium of the follicles is swollen and proliferated, 
and there is infiltration of the surrounding connective tissue with 
round cells. In severe forms the surface of the mucous membrane 
is covered with mucus containing leucocytes and blood-cells. The 
follicles are elevated above the surface. In other cases the intestine 
is studded with ulcerations which mark the necrotic follicles. The 
ulcerations reach to the muscularis mucosa?. If the process extends 
to the small gut, the Peyer's patches are swollen and surrounded by 
a hypersemic zone. 

If the disease has advanced to the necrotic stage, the mucosa is 
thickened and infiltrated with round cells. There are areas of loss 
of tissue which extend deep to the muscular coat (gangrene). The 
mucous membrane is covered with a grayish exudate of a pseudo- 
membranous character. In severe cases large areas of the mucous 
membrane may necrose and be cast off. The necrotic areas show 
an abundant invasion of bacteria of the coli type, in scattered masses 



DYSESTERY. 



331 



or zoogloea. The lymph-nodes of the mesentery are swollen ; the 
spleen may be enlarged ; the kidneys may show degenerative 
changes, and the lungs may be the seat of bronchopneumonia. 

The symptoms of dysentery in infants and children closely re- 
semble those seen in the adult subject. The onset may follow some 
indiscretion of diet or be entirely independent of any such error. 
There may be a preceding headache, and there is, as a rule, some 
fever. Abdominal pain is the lirst symptom until diarrhoea sets in. 
The diarrhoea at first resembles an ordinary dyspeptic diarrhoea, but 
in a few hours or after one or two movements, it assumes the charac- 
teristics which mark it as specific. The patient passes stools which 
are fluid and contain mucus mixed with blood and shreds of tissue, 
and which may have an offensive odor. They are passed with much 
abdominal pain and rectal tenesmus. If the abdominal pain is 
severe, there are vomiting and great prostration. As many as twenty 

Fig. 91. 



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Dysentery of ordinary severity. First week of illness. Duration three weeks; recovery- 

Boy, seven years of age. 



to thirty small bloody mucoid movements may be passed daily. The 
fever varies in intensity. In mild cases the temperature may range 
from 101° to 102° F. (38° to 38.5° C.) (Fig. 91); in severe 
ones it may reach 104° (40° C.) (Fig. 92). If the disease persists 
beyond a few days, there is rapid emaciation and the abdomen 
becomes sunken and board-like. In some eases palpation in the 
region of the caecum and ascending colon may detect the contracted, 
thickened gut. In one case of the necrotic type, 1 could during life 
mark out the caecum and ascending colon as a contracted, thickened 
tube. In protracted cases the spleen becomes enlarged and the 
tongue dry and coated, in this respect resembling the condition >ww 
in typhoid fever. Multiple hemorrhages may appear under the skin. 
The urine contain- albumin, and in some cases hyaline and epithelial 
casts. 



332 



DISEASES OF THE GASTRO-ENTERIC TRACT. 



Course. — The fulminating cases run their course in a few days 
with high fever, terminating in death. Other cases may be com- 
paratively mild and last only a few days or a week. In such cases 
there may be recurrences. In other cases the disease runs a course of 
from three to six weeks. After this period, from time to time, blood, 
evidently derived from bleeding ulcers in process of repair, may 
appear in the movements. The movements gradually become formed 
and fecal in character, and the patient recovers. In cases which 
have come under my care in hospital service, the disease ran a moder- 
ately severe course until the seventh or eighth day. The fever, how- 
ever, remained high and delirium set in on the ninth day. The 



Fig. 92. 



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Necrotic colitis ; fatal, in a girl six years of age. 



appearance of the patient became septic, sopor supervened, and the 
urine and feces were passed involuntarily. Death took place on the 
thirteenth day. In other cases of a severe necrotic type death took 
place at the end of a week. 

Complications. — The most dangerous complication is perforation 
and general peritonitis. Periproctitic abscess may occur, with sub- 
sequent fistula. In septic cases, abscess of the liver and spleen have 
been observed. Hemorrhages may occur under the skin late in the 
disease. In all of my cases these were quite extensive, but recovery 
nevertheless took place. In one fatal case I noted metastatic paroti- 



DYSENTERY. 333 

tis. Some authors have recorded arthritis as a complication ; as a 
rule it retrogrades and recovery takes place. 

The prognosis varies with the severity of the ease. The mor- 
tality ranges from 30 to 40 per cent. The croupous or necrotic 
cases are very fatal. With good management the mild cases give 
a favorable prognosis. The severity of the infection and the 
prevalence of an epidemic will influence the course of the affec- 
tion. 

Treatment. — Prophylaxis. — The movements are not only infec- 
tious, but may also communicate the disease to others if a particle 
is introduced into the gut. The hands of the patient and his 
body should be kept scrupulously clean to avoid reinfection. The 
movements should be disinfected in the same manner as those of 
a patient suffering with typhoid fever. The hands of the nurse 
should be scrupulously cleansed and washed in an antiseptic solu- 
tion. 

The patient is given a cathartic, preferably castor oil, as the initial 
step of treatment. In this way all irritating food particles and 
residual feces are cleared from the gut. All food, even milk, is with- 
held at first. The patient for the first twenty-four hours is given a 
solution of egg-albumin, acorn-cocoa, beef-juice broths, or expressed 
beef-juice and barley-water in equal parts. The following are the 
lines along which the later management of these cases should 
proceed : 

a. An absolutely non-irritating and easily assimilable food is 
given. 

6. The pain and tenderness are relieved with drugs, the diarrhoea 
being also partially controlled in this manner. 

c. The rectum is irrigated. 

d. After a day or two, during which the patient has been fed 
upon albumin-water, expressed beef-juice, and barley-water or acorn- 
cocoa solutions, sterilized or pasteurized milk is substituted. In 
these cases, as in typhoid fever, the patients arc given during twenty- 
four hours, two or more quarts of milk sterilized at 212° F. (100° C.) 
or pasteurized at 104° F. (73° C). I wait until the severely acute 
symptoms have subsided before placing these patients on a milk diet. 
At best, milk leaves a large residue in the gut, and in the acute stage 
of the disease the coagulum may in a mechanical way irritate the 
acutely inflamed walls. Pasteurized and sterilized milk is well 
borne in the later stages of the affection. Milk in a raw state, no 
matter how good, will sometimes tend to aggravate the acute symp- 
tom-. Pain and tenesmus are relieved by the exhibition of Dover's 
powder, grains j to ij (0.03 to 0.12), every two hours according to 
the age of the infant or child. Codeine sulphate, grain \ to \ (<>.<>1 
to 0.015), according to the age of the patient, is preferable to mor- 
phine or tincture of opium. The administration of powdered ipecac- 



334 DISEASES OF THE GASTRO-ENTERIC TRACT. 

uanha will be found very useful in certain cases. In others the 
vomiting rather interferes with its administration ; grains j to ij or 
iij (0.06 to 0.12 or 0.2) every two or three hours are indicated. It 
may be combined with bismuth subcarbonate, grain v (0.3) every 
three hours. 

In older children this mode of treatment has lately given good 
results. I have had no experience with the administration of lead 
salts. In the acute cases the internal administration of prepara- 
tions, such as tannigen, is irritating. 

Rectal enemata should be employed with care in the treatment of 
colitis or dysentery. Unless caution is exercised, their use is in 
many cases followed by an exacerbation or perpetuation of symp- 
toms. The most useful form of enema is the warm (108°-110° F., 
42.2°-43.3° C.) saline (Cantani) solution. Fully a quart of fluid 
is allowed to flow into the gut. The greater part of it returns, but 
I believe that if a portion of this solution is retained it acts in the 
manner of enteroclysis and supports the patient. These enemata are 
given three times in the twenty-four hours, for a day or two ; they 
are subsequently given twice a day, and finally, as the symptoms sub- 
side, only once a day. I have never been able to convince myself that 
silver nitrate (1 : 1000) or tannic acid added to the enemata is of 
value. On the contrary, I believe that in cases in the acute stage 
these medicated enemata are distinctly irritating. In the later 
stages of the disease, small quantities of fluid blood are passed with 
the fecal movements, tenesmus being present ; small enemata of 
silver nitrate (1 : 1000) given low down twice daily cause cessation 
of the bleeding which is due to the presence of ulcers low down in 
the rectum. In the subacute stage, the enemata will often be fol- 
lowed by an exacerbation of bloody mucous passages. Under these 
conditions it is well to discontinue the enemata and to watch the 
results of the suspension of local treatment. 



AMCEBIC DYSENTERY. 

Amoebic dysentery is not, strictly speaking, a disease of infancy 
and childhood. It is caused by the Amoebae coli of Losch. Of 
35 cases reported by Harris, 4 were under ten years of age. Amberg 
has recently published 5 additional cases. The etiological factor is 
the Amoebae coli, Avhich are found in large numbers in the movements. 
With the amoeba, Charcot-Leyden crystals are found in most cases. 
The cases published by Amberg were of a mild type, and seemed in 
no way to differ in symptomatology from the form of the disease 
seen in the adult subject. There were diarrhoea of a bloody character, 
tenesmus, and in some cases fever and prostration. As many as from 



CONSTIPATION. 335 

four to six movements containing blood and mucus, and microscopi- 
cally eosinophile cells, were passed in twenty-four hours. 

The diagnosis is made from the presence of the amoebae in the 
movements. Bloody passages containing Chareot-Leyden crystals 
should cause the physician to entertain a suspicion of the presence 
of this affection. 

Other amoebae, such as the Monocercomonas hominis (Grassi), have 
been found in the movements of infants suffering from diarrhoea. 
Epstein describes an epidemic of diarrhoea in which the monocer- 
comonas abounded in the movements. He thinks that in this epi- 
demic the diarrhoea was caused by well-water which contained the 
amoeba?. I have found the Monocercomonas hominis in the move- 
ments of infants who were suffering from diarrhoea, but also of those 
whose bowels were not in an abnormal condition. The role of the 
monocercomonas as an etiological factor in the causation of these 4 
diarrhoeas is not understood. It is doubtful whether they have any 
causal connection with the diarrhoea. 



CONSTIPATION 

(including the So-called Mucous Colitis or Mucous Disease). 

Of all the conditions within the domain of pediatrics, consti- 
pation is the most difficult of treatment. It is not always possible 
to fix upon the cause of a constipated habit in infants. Infants at 
the breast may be constipated from birth and continue this habit 
through childhood, although normal in other respects. Sometimes 
the mother is of constipated habit. Slight rachitis may be present 
in particular cases. It is reasonable to conclude that some substance 
necessary to the normal action of the gut is lacking in the milk. 
After a time fissuration of the anus is developed and becomes a per- 
petuating cause of the constipation. 

Rachitis, when marked, is associated with constipation in a large 
proportion of eases. The whole muscular apparatus lacks tone, 
and it is not surprising that both the muscle and the glandular 
apparatus of the gut lack power to perform the functions which 
are necessary to the maintenance of a normal state of the intestinal 
contents. 

Hereditary influence has been named as a cause. I have met many 
cases of constipation in breast-fed and bottle-fed infants whose par- 
ents suffered from a similar condition of the gut. 

Incorrect feeding is certainly a frequent cause of constipation in 
artificially fed infants and children. Some children who partake of 
boiled, sterilized, or pasteurized milk, become obstinately consti- 
pated, the condition being especially marked if the milk is subjected 



336 DISEASES OF THE GASTRO-ENTERIC TRACT. 

to a temperature above 165° F. (73.5° C). If there is a dimin- 
ished quantity of fat in the milk, constipation will sometimes result. 
In older children a deficiency of certain articles of diet will cause 
constipation. 

The role of fissure and eczema of the anus in causing and per- 
petuating constipation has been mentioned. In older children lack 
of exercise, nervous temperament, and lack of correct habits of 
evacuation of the bowel will cause constipation. 

An account of the congenital anomalies and malformations of 
the gut and rectum as a cause of constipation does not lie within the 
scope of this section. 

Symptoms. — One can scarcely speak of the symptoms of a con- 
dition which is itself a symptom. There are, however, certain features 
of the movements of constipated infants and children which are of 
importance. 

Movements. — The movements of an infant suffering: from consti- 
pation may be hard and formed, or may be unformed but dry. The 
movements in other cases consist almost entirely of marble-like 
masses resembling those seen in lower animals. Infants who are 
constipated do not have a movement unaided. In passing the move- 
ment they have pain, due in some cases to a fissuration and stretch- 
ing of the anus by the hard masses. In other cases the fissures bleed 
at every movement. This bleeding, with slight prolapse of the gut 
during the movement, often creates the impression that the infant is 
suffering from a condition resembling hemorrhoids. Many move- 
ments are dry, others contain shreds and large masses of mucus or 
pseudomembranous structures. These masses are composed princi- 
pally of mucus, and are not true membranes. The amount of mucus 
varies. The movements may be coated externally with the mucus or 
it may be passed in separate masses. 

Frequently, infants and children do not appear to suffer from any 
ill effects as the result of constipation, but sometimes, and especially 
in children from the fourth to the sixth year, constipation is accom- 
panied by crises of vomiting which occur at irregular intervals and are 
indicative of a species of intestinal toxaemia. Eustace Smith has 
described a similar condition under the heading of mucous colitis. It 
is probable that the mucous colitis is a result of the constipation 
rather than a primary condition. The attacks of intestinal toxaemia 
in constipated children begin with vomiting and dizziness. For a 
day or two prior to the attack the patients are noticed to be pale and 
listless ; on awakening in the morning they complain of vertigo, 
nauseated feelings, and begin to vomit. At first some article of food 
ingested on the previous day is vomited. The vomiting persists even 
when the patient is in the recumbent posture. Anything taken into 
the stomach may be vomited — even water. After a time the vomited 
matter contains bile-pigment. The stomach may for a time tolerate 



COXSTIPATION. 337 

small quantities of fluid. These collect in the stomach and are finally 
vomited, the quantity vomited being equal to that taken into the 
stomach. The pulse is rapid and bounding ; the cardiac impulse is 
forcible, resembling that seen in cardiac hypertrophy. The temper- 
ature may be elevated a degree above the normal, but rapidly becomes 
normal. In some cases there is pain about the umbilicus j there is 
no distention of the abdomen. The face is pale and anxious, and 
the patient appears greatly prostrated, as if suffering from a severe 
illness. The urine contains albumin ; the urea is diminished, and at 
first there may be numerous hyaline and epithelial casts, which disap- 
pear after the subsidence of acute symptoms. The urine also contains 
ammonium urates. The vomiting subsides if the stomach is given rest, 
and in two days the patient appears to have made a recovery. During 
this time there is no movement from the bowel except with the aid 
of cathartics and enemata, but by these means good movement may 
be obtained, showing that there is no obstruction of the gut. Attacks 
are apt to recur. After the attack there is mucus in large quantities 
in the feces. It gradually diminishes in quantity, and finally under 
correct treatment disappears, but may reappear at intervals in vary- 
ing quantity. 

The treatment of constipation is dietetic, medicinal, and sur- 
gical. 

If the infants who are constipated are fed at the breast, the 
mother's bowels should be regulated, and she should take regular 
exercise. In many cases the taking of nutritious diet by the mother 
will cause the milk to become changed in constitution and more 
abundant. In some cases, on the theory that the mother's milk is 
deficient in fats, the infants are given cream at regular intervals 
before nursing (Biedert, Holt). A teaspoonful of cream containing 
16 per cent, of fat is given three or four times daily before nursing, 
with the result that in a day or two the bowels become regular. 
Sometimes infants under this treatment vomit or have diarrhoea! 
movements, especially in the summer. In other cases the infants 
continue constipated in spite of the administration of cream, and 
must be treated with drugs and massage. If artificiallv fed children 
are constipated, the heating of the milk should be stopped. If for 
some reason milk must be pasteurized or sterilized, the time of heat- 
ing should be reduced to a minimum. Constipated infants may 
be fed on raw milk if the milk is fresh and carefully kept. The 
formula Bhould contain sufficient fat to make the diet nutritious, but 
the fat Bhould not form more than 4 per cent, of the mixture. As a 
rule, artificially fed infants do well on a smaller quantity of fat 
than the average breast-fed infant. Thus 2.5 to 3 per cent, of fat 
meet the requirements of most infants. W they are constipated, 
the fats are raised to 4 per cent. This proportion should not be 
increased, since there is danger of disturbing the functions of the 

22 



338 DISEASES OF THE G ASTRO-ENTERIC TRACT. 

gut to such an extent as to give rise to conditions more serious than 
the constipation. 

Children from the sixteenth month to the second year who suffer 
from constipation should be gradually weaned to a mixed diet. In 
many cases this procedure will regulate the bowels. The children 
should be given green vegetables, such as peas and spinach, in the 
form of a puree. The diet should include cereals of the various 
varieties, especially wheatena, oatmeal, granum, and rusk (Zwieback). 
The milk should be given raw with a moderate mixture of cream. 
Fruit, such as oranges, raw apples, and pears, is also given in moder- 
ation. If the constipation cannot be remedied by these measures, 
recourse is had to medicinal treatment. 

Cathartics. — At best, cathartics are a makeshift. Some older 
children will do well with a small dose, grain yi^- (0.0004), of 
strychnine once a day, and a simple cathartic, such as the aromatic 
fluid extract of cascara, twice or three times a week. A child two 
years of age may be given TTL xx to xxx (1.0 to 2.0) once a day. 
TKe preparations of rhubarb are useful, but do not give uniformly 
satisfactory results. The mercurial cathartics are available only once 
a week in the majority of cases. We are thus reduced to the neces- 
sity of giving suppositories or enemata. With very young infants a 
small cylindrical piece of soap inserted with oil into the rectum once 
a day will be effective. With older children the glycerin suppository 
given every other day is very useful. 

Enemata. — In many cases it is necessary to give enemata : to 
younger infants they are given once a day ; to older children affected 
with the form of constipation occurring in connection with mucous 
colitis, an enema is given twice a week. The diet in these cases of 
mucous colitis should be carefully regulated ; the movements are 
inspected, and articles of diet which are observed to pass undigested 
through the gut are avoided. When the child becomes pale and list- 
less a brisk cathartic aided by a large high enema is given. In 
this way the attack of vomiting may be avoided. In cases of mucous 
colitis accompanied with crises of vomiting the children are kept in 
bed at the time of the crisis. No food of any kind, not even fluids, 
is given by the stomach. High rectal enemata are given twice daily. 
Somatose in solution is given by rectum, an ounce (30.0) three times 
daily. If vomiting persists, codeine is given in doses of grain 
\ (0.01) by mouth. After twenty-four hours the administration of 
milk by mouth is begun cautiously. The diet list is gradually aug- 
mented, one article of diet being added daily until the child is 
taking a moderate fluid diet. When the stomach has become more 
tolerant a brisk saline cathartic, preferably Carlsbad salts, is given in 
milk. The patient is then gradually advanced to a full diet. In 
these cases it is of the utmost importance to discover what articles 
of diet agree with the patient. This can only be done by trying 



ACUTE INTESTINAL OBSTRUCTION. 339 

each article in succession and inspecting the movements with a view 
to ascertaining the amount of residue. In convalescence the daily 
enemata are continued. These patients do well with some cathartic, 
preferably easeara, twice a week. Rectal enemas given twice a 
week should be continued for some length of time. Acidi muriatic, 
dil., TTl ij (0.12), and pepsin, grains ij (0.12), t. i. d., will greatly aid 
stomach digestion in older children if there is pain after eating. 

Massage. — Massage of the abdomen gives very unsatisfactory 
results. Gymnastics or calisthenic exercises in the morning after a 
bath are useful in some cases. 

Useful formulae are the following : 

1. Pulv. glycyrrhiza? comp. . . ^ss to £j (2.0 to 4.0) as necessary. 

2. Infus. senna? comp oJ~3y (4.0-8.0) as necessary. 

3. Podophyllin gr ij (0.12). 

Syr. rhei arom 31J (60.0). 

Sig- 3J ( 4 -°) prodosi. 

The bitter waters may be given to older children as to adults. 
Surgical treatment is directed toward remedying any local condi- 
tion which may be present, such as fissure or spasm of the anus. 



ACUTE INTESTINAL OBSTRUCTION. 

(Intussusception.) 

Intussusception, according to Treves, is the prolapse of one part 
of the intestine into the lumen of an immediately adjoining part. It 
causes more than one-third of all the varieties of obstruction of the 
gut. 

Varieties. — Invagination of the gut may take place in any part, 
from the duodenum to the rectum. There are the following forms : 

The enteric form, which may involve any part of the small intes- 
tine, but which most commonly involves the lower part of the 
jejunum or the ileum. 

The colic form, which may involve any portion of the colon. 

The ileocecal, which i> the most common form. 

In the ileocecal variety the ileum and caecum pass into the colon, 
the valve preceding and forming the apex of the intussusception. In 
the ileocolic form, the valve remains stationary and the ileum pi 
into the colon. In the latter form there is an invagination of the 
caecum and colon, of a secondary character. 

Etiology. — Nothnagel demonstrated that intussusception is caused 
by irregular muscular action in the wall of the gut; in acute intus- 
susception this Is of a spasmodic character. In 50 per cent, of the 
- little i- known of the exciting cause. 



340 DISEASES OF THE GASTRO-ENTERIC TRACT. 

Diarrhoea, the various forms of enteritis, polypi, and diverticula, 
improper food, traumatism, and exposure to cold, have all been 
regarded as exciting causes. Typhoid fever and pertussis have been 
complicated or followed by intussusception. I have recently seen a 
case following typhoid fever in a boy three years old. 

Meckel's diverticulum and the appendix have been the cause and 
seat of intussusception. In the latter case the inverted appendix 
caused ileocecal intussusception. 

Frequency. — Intussusception is more -common in males than in 
females. The disproportion diminishes after the first year of life. 
Fifty per cent, of all the cases occur before the tenth year, and chiefly 
in individuals who are not in good physical condition (Treves). In 
the cases that I have seen, the infants were delicate, the child being 
robust in only one case. 

The youngest case I have met was five and a half months of age. 
This infant was breast fed, had suffered with colic, and had had 
green movements from birth ; there was an ileocsecal invagination 
eight inches in length. 

Symptoms. — The onset is sudden in 75 per cent, of the cases ; 
in the colic and rectal varieties it may be gradual. In many cases 
the disease makes its appearance while the infant is nursing or 
during sleep. The patient, being attacked with pain, suddenly 
awakes from sleep with a cry and begins to vomit ; on the same 
day or the following day a bloody movement appears, the amount of 
feces being small. In a few cases there are no fecal evacuations. If 
the case is progressive, the pain returns in paroxysms, the hemorrhagic 
movements are repeated, and the vomiting keeps pace with the in- 
crease of the obstruction. The general condition of the patient 
grows worse ; apathy and collapse ensue. I have seen cases begin 
with a mild diarrhoea ; the pain suddenly appears, and also the 
hemorrhages from the bowel, the infant at once going into collapse. 
There is apathy, from which it is difficult to rouse the patient. If 
the case continues to progress, the movements become frequent, ex- 
haustion increases, and finally death from asthenia results. The pain 
is great at the onset, usually reaches its maximum intensity within a 
short time, and then gradually subsides. It is of a paroxysmal char- 
acter and is colicky during the advance of the invagination ; as 
adhesion takes place or gangrene occurs it diminishes. The intervals 
between the paroxysms of pain are at first of considerable length ; 
later they become shorter. The pain is most severe in the ileocecal 
form, and is in all forms caused by irregular intestinal peristalsis. 

Vomiting is not so prominent a symptom as in other forms of 
intestinal obstruction (Treves). In 75 per cent, of the cases it 
comes on early with or directly after the pain. It may not recur for 
hours. In a child taken with sudden pain of a colicky character, 
vomiting, and bloody stools, the vomiting recurred only twice within 



ACUTE INTESTINAL OBSTRUCTION. 341 

twenty-four hours. It is apt to be less violent as long as there is 
not complete obstruction of the gut ; in other words, it is more 
marked in those cases in which no feces pass through the gut. As 
long as the pain recurs in paroxysms (progression of the intussuscep- 
tuin) the vomiting is not apt to be marked. The vomited matter is 
composed of the stomach contents and is biliary ; stercoraceous 
vomiting was found late in only 25 per cent, of Leichtenstern's cases ; 
Gibson also found it to be rare and late. If stercoraceous vomiting 
was present, it appeared from the fourth to the seventh or to the 
fourteenth day. In the case referred to, in the infant of five and 
one-half months, it appeared during the first twelve hours of the 
disease. 

The condition of the bowel is important. It is generally stated 
that constipation occurs from the outset ; this is not universally true. 
Cases in which constipation exists throughout, that is to say, in 
which no feces whatever are passed, are not common, and form only 
30 per cent, of the total number. Diarrhoea is the common condition 
at the outset ; as the obstruction increases, the amount of feces in 
the stools diminishes, and finally only mucus and blood are passed. 

The most important symptom in connection with the bowels is 
hemorrhage. Hemorrhage from the bowel, in connection with pain 
and other abdominal symptoms, is considered by Gibson as pathogno- 
monic. It was present in 80 per cent, of the cases tabulated by 
Leichtenstern. As a rule it is considerable. It is said by Treves 
to have been in some cases so great as to cause death. The blood and 
feces have a cadaveric odor, which however is not always, as some 
writers affirm, a sign of gangrene. I have perceived this odor in an 
intussusception which operation showed not to be the seat of gan- 
grene. It is caused by decomposition of the blood in the gut. 

The temperature is normal, slightly subnormal, or slightly ele- 
vated. There may be a slight elevation of temperature without peri- 
tonitis. The quantity of urine may as in other forms of intestinal 
obstruction be diminished. 

Tenesmus is present in 55 per cent, of the cases; it depends more 
or less on the presence of the intussusception in the rectum. It is 
usually an early symptom in the rectal form, and is more common 
in the ileocecal variety than in the enteric. 

The abdomen is not at first distended ; it may, on the contrary, 
be retracted; if tympanite- occurs at all, it does so late and in the 
nee of a general peritonitis. Palpation of the abdomen is at 
first well borne, but after a time there is sensitiveness. 

A tumor felt through the abdominal wall or in the rectum is of 
the greatest value in the diagnosis. It cannot be felt if the intus- 
susception is in the hepatic or -picnic flexure of the colon. It is 
variable in distinctness, and is most frequently felt in the region of tin; 
descending colon or of the sigmoid flexure. It is hard and resistant, 



342 DISEASES OF THE GASTRO-ENTERIC TRACT. 

and rarely more than six inches long. It is often said to be sausage- 
shaped, but the statement is misleading. The tumor is rarely felt in 
the ileocecal region, for the reason that the intussusception in this 
locality is small, and is that of a small gut inside of a large one. In 
one-third of the cases the rectum, if examined, shows the presence of 
the intussusceptum. The rectal tumor is commonly found in children, 
because in them the colon is mobile. The gut may reach the anus 
as early as the second day, the average time being the seventh day. 
It may protrude from the anus from three to eight inches, and may 
be in a gangrenous state ; under these conditions it has been mis- 
taken for a polypus or hemorrhoid. 

Prognosis. — As regards duration, there are three varieties of 
intussusception — the ultra acute, the acute, and the subacute. The 
ultra acute cases are exceedingly rare. Leichtenstern found only 
5 of this form in a total of 7269 cases ; 4 of the 5 occurred in 
infants less than a year old. All were fatal. 

The rate of mortality in intussusception, excluding the ultra 
acute forms, varies as given in the statements of different authors. 
Gibson's statistics place the mortality at 53 per cent. It varies 
with the age of the patient, the duration of the disease before 
operating, and the success in reducing the intussusception. In- 
tussusception is extremely fatal in infants under the first year. 
Thus according to Treves, the mortality under one year of age is 80 
per cent. On the other hand, if we study the cases as Gibson has done, 
we find that the cases operated on during the first day of the dis- 
ease had a mortality of 41 per cent.; those on the fourth day, 72 
per cent. The reducible cases showed a mortality of 38 per cent.; 
the irreducible, of 88 per cent. 

Diagnosis. — From the studies made by Gibson, it may be seen 
that, in children, a bloody discharge with abdominal pain of a 
paroxysmal nature is almost pathognomonic of intussusception. 
Fecal vomiting is of very little value as a diagnostic sign. It is 
very infrequent, and is in any case present only late in the disease, 
when occlusion of the gut has occurred. If enteritis exists in a 
young infant, it is often difficult in the absence of any abdominal 
or rectal tumor to make a diagnosis. The course of the case will 
guide the physician. In dysentery the hemorrhage from the bowel 
is not great ; it is composed of blood-tinged mucus. Appendicitis 
has been mistaken for intussusception. It frequently occurs with 
it, and thus obscures the picture. Peritonitis can hardly be mis- 
taken for intussusception. In peritonitis the pain is continuous 
and there is tympanites, but no bloody discharge. Tuberculous 
peritonitis is sometimes mistaken for intussusception. In tubercu- 
lous peritonitis the symptoms are not progressive, and also there is 
not likely to be a bloody discharge. 

The case following typhoid fever, to which I referred, simulated 



ACUTE INTESTINAL OBSTRUCTION 343 

a hemorrhage from a typhoidal ulcer. A careful examination under 
an anaesthetic cleared up the case. In complete relaxation under 
anaesthesia, a tumor could be felt in the caecal region of the ascend- 
iug colon. The result of examination was verified by operation. 
In all doubtful cases in which the restlessness of the child interferes 
with a careful examination an anaesthetic should be given. There 
is a characteristic condition which in some cases can be detected by 
examination. As the finger is inserted into the anus the rectum is 
felt to be inflated. This is due to traction on the gut by the in- 
vagination. I have found this inflated state of the rectum in two 
infants suffering from intussusception. 

Spontaneous Cure. — There is little doubt of the possibility of 
spontaneous recovery in invagination ; such cases have been recorded 
by competent observers. Henoch has seen typical intussusception 
retrograde and the patient recover. There is another mode of 
recovery which occurs in cases of irreducible intussusception : the 
intussusceptum sloughs off and is passed per anum. This occurred 
in 43 per cent, of the unrelieved cases (Leichtenstern), but in 40 per 
cent, of these the patient succumbed to general sepsis with or with- 
out peritonitis or to subsequent obstruction of the gut from swell- 
ing after the gangrenous portion was passed. Henoch reported a 
case of this kind. 

Treatment. — The diagnosis of intussusception once made, the 
case is one for surgical interference. The sooner surgical treatment is 
begun, the better the chances of recovery. Injections of air, gas under 
pressure, and enemata of water and oil have been tried, with some 
measure of success. Their use, however, delays the radical treatment, 
and apparent improvement frequently gives way to an exacerbation 
of symptoms. Surgical aid then comes too late. The objections to 
the treatment by injection are as follows : the gut is viable in these 
cases, and is liable to be ruptured by injection of gas or air under 
pressure ; an enema of water under only four feet of pressure has 
been known to produce this result. Snow published a case in which 
an injection of oil was made; post mortem the oil was found above 
the point of obstruction. The enema may thus pass through the 
lumen of the gut without relieving the intussusception. Enemata 
should be given, if at all, during the first forty-eight hours, and 
should be allowed to flow into the rectum under very low pressure. 
The amount of fluid varies; certainly not more than a quart should 
be given. The fluid, a saline solution at 100° F. (o7.7° (\), is 
allowed to remain in the rectum for ten minutes, the patient being 
under an anaesthetic. A Davidson syringe should not be used. The 
ordinary bag irrigator is best for this purpose, Jf one enema fails 
and the diagnosis is certain, there should be no delay in seeking 
surgical assistance. 



344 DISEASES OF THE G ASTRO -ENTERIC TRACT. 

APPENDICITIS. 

( Perityphlitis; Paratyphlitis. ) 

Anatomical Peculiarities. — Valine examined the appendix in 
100 infants and children post mortem. He found that in fully 75 
per cent, the caecum is situated above the anterior superior spine, 
on the right side, a position higher than that occupied in the adult. 
It is above the plane of the anterior superior spine of the ileum, 
is almost 5 centimetres long, and has a general longitudinal ascend- 
ing or descending direction. In one case the appendix was situated 
entirely to the left of the median line, there being no transposition 
of the other viscera. Knowledge of these facts is of importance in 
the examination for the appendix in conditions of disease. I have 
frequently succeeded in palpating the normal appendix at one side 
of the ca?cum. It is felt as a cylindrical body having the diameter 
of a quill. 

Acute Appendicitis. 

Frequency. — Although the statistics showing the frequency of 
appendicitis in infancy and childhood vary with the number of cases 
collected by each author, the combined statistics of Matterstock, 
Fitz, Sonnenburg, and Nothnagel, show that the disease is not very 
frequent before the tenth year. Only 8 per cent, of the cases occur 
at this age. It may occur in early infancy. Savage records a case 
in an infant two months old ; Demme also records a case in a very 
young infant. 

The literature show T s occasional cases at all periods of infancy. 
Among the cases collected and tabulated from the service of my 
colleagues, Gerster and Lillienthal, at the Mount Sinai Hospital, 
there is one of an infant one year of age. Of 50 cases of appendi- 
citis in children taken from the service of these surgeons, 1 occurred 
in an infant one year of age, 17 from the third to the sixth year, 
and 32 from the sixth to the tenth year of life. Thus in a statistical 
collection of cases occurring in children, only one-third occurred 
before the sixth year of life. 

The forms of the disease are the same as in the adult subject. 
The perforative form seems to be the most common among children. 
Thus of 50 cases coming to the hospital for operation, 31 were per- 
forative with or without abscess, 9 were of the gangrenous variety, 
and 6 of the catarrhal form. It will thus be seen that in children 
the tendency in this disease as in others, such as pleurisy, is toward 
suppuration and the formation of abscess. 

The symptoms will vary with the variety, whether catarrhal, 
perforative, or gangrenous. 

a. In the catarrhal form the patient is, after some indiscretion 
in diet, seized with colicky abdominal pain, vomiting, and some 



ACUTE APPENDICITIS. 345 

fever. Id other eases the children simply complain of pain which 
is not sufficiently severe to prevent their being up and about. The 
pain is not always located by the patient in the appendix. When 
the patients are in the recumbent posture, the right knee may be 
flexed and the thigh flexed on the abdomen ; when they walk, they 
do so in a bent position, favoring the affected side. Physical ex- 
amination reveals a localized resistance or tenderness in the right 
iliac fossa. In some cases there is distention of the caecum with 
feces, in others I have felt the appendix and the caecum matted 
together in a mass of the size of the index finger. 

The pain is not always referred to the iliac fossa, but may be 
distinctly located around the umbilicus or over the lower part of 
the abdomen. 

It may not always be possible to palpate the appendix, which 
may be behind the caecum. Under such conditions no intumes- 
cence will be found. McBurney's point will be considered in the 
diagnosis. 

The history of many of the catarrhal cases is one of recovery 
under careful treatment. The fever subsides or may never have been 
above 101° F. (38.3° C.) ; the pain also subsides, and in from a 
few days to a week the patient is apparently well. Attacks of this 
kind may recur. 

6. In the perforative or suppurative form the symptoms are more 
violent. In this form also the onset of the disease seems to date from 
some indiscretion in diet. The patient is seized with sudden sharp 
pains in the abdomen, accompanied by vomiting, fever, and rapidity 
of pulse. The pain is located either in the upper or the lower part 
of the abdomen, or in a few cases in the right iliac fossa. After 
one or two attacks of vomiting this symptom may subside and not 
recur until the second or third day, when perforation occurs. Tym- 
panites occurs early and may set in after the second day of the dis- 
ease. The pain and tympanites cause an increase in the respiratory 
movements, which are shallow. The patients lie in the recumbent 
posture. The tympanites, if the perforation is extensive and there 
is general peritonitis, causes, as in all forms of perforation, a disap- 
pearance of the liver dnlness. The pulse is at first rapid and thready, 
and quickly mounts above 120 after perforation has occurred. The 
prostration is great, and in some cases of a septic type jaundice is 
present. 

f. In the gangrenous form the symptoms are very similar to 
those of the perforative form, but are very much intensified. It is 
not po.-sible to tell from the symptoms whether the process is gan- 
grenous, simply perforative, or catarrhal followed by abscess. 

Course. — in both the perforative and the gangrenous cases in 
children as in the adult, localized adhesions may form with a small 
or large collection of pus or several foci of pus. In other cases a 



346 DISEASES OF THE G ASTRO-ENTERIC TRACT. 

general peritonitis follows the perforation. In children, as in adults, 
the moment of perforation is followed by a temporary fall in the 
temperature and a cessation in the pain and vomiting, the pulse, 
however, continuing rapid. The lull, however, is of short duration, 
and is quickly followed by an increase in the severity of the symp- 
toms. 

Diagnosis. — The above outline gives very little idea of the great 
and sometimes insurmountable difficulties of diagnosis of appendi- 
citis in young children. To guard against error, a very careful 
routine should be followed. The patient is completely undressed 
and lies in the recumbent posture, the shoulders being slightly raised. 
The physician should stand or sit at the patient's right. The contour 
of the abdomen is noted. If it is normal and not distended, there is 
probably no peritonitis. The abdomen is very gently palpated in differ- 
ent places to ascertain if there is distributed or localized tenderness. 

Fig. 93. 




Method of examination of the region of the appendix vermiformis. 

The left palm is then placed underneath the right loin, and with the 
palmar surface of the fingers of the right hand the region of the 
appendix is gently palpated (Fig. 93). Superficial palpation is 
practised at first. The hand is then depressed deeper into the iliac 
fossa in search of resistance or tumor. The intensity of the pain 
caused by manipulation is carefully gauged by watching the face of 
the patient. The right iliac region having being carefully palpated, 
rectal exploration should be made in all doubtful cases. This is 
necessary in the cases in which a general tympanites or general 
abdominal tenderness makes the diagnosis difficult. With the well- 
oiled index finger of the right hand the rectum is explored as high 
up as possible. In young children this can be done without causing 
pain if gentleness and caution are exercised. If children are very 
intractable, this method of examination cannot be carried out. 



ACUTE APPENDICITIS. 347 

The following points are important in the diagnosis : 

Tympanites. — If the abdomen is distended and there is general 
pain with increase of the number oi' respirations, there is probably 
peritonitis localized or diffuse. In the latter ease there is disappear- 
ance of the liver dullness if the tympanites is extreme. 

Percussion will sometimes, even in general peritonitis, give a 
localized dulness in the right iliac fossa. Localized pain and in- 
tumescence or a localized mass in the right iliac fossa are of great 
import. 

McBurney's point is of less value in children than in the 
adult. Iu children, as will be seen from Vallee's work, the appen- 
dix is situated higher than in the adult, and McBurney's point is 
therefore too low for palpation. Some children complain of epi- 
gastric, others of umbilical pain, which is not so distinctly localized 
as in the adult. 

The fever is of little value, there being nothing characteristic in 
the curve. The temperature may be normal or in severely septic 
cases slightly raised. After perforation, the temperature becomes 
subnormal, as it does in the adult. 

Appendicitis iu children may simulate tuberculous peritonitis. In 
the latter disease there is sometimes severe pain of the colicky 
variety. Tuberculous peritonitis and appendicitis may be coinci- 
dent. 

Pain in appendicitis resembles very closely that in gastro-enteritis 
and dysentery. Griffith has published 2 cases of appendicitis in 
children who had entero-colitis at the same time. 

I have had one case in which a perinephritic abscess simulated an 
appendicitis. The contrary may also occur. Appendicular abscess 
may simulate a coxalgia with abscess. I have seen a few cases of 
typhoidal affection of the appendix which for a few days simulated 
an appendicitis very closely. Appendicitis with invagination of the 
appendix into the caecum is a rare condition, as is also intussuscep- 
tion with appendicitis. In the typhoidal cases, a Widal reaction 
may be obtained, and will be of assistance in diagnosis. (arc 
should be taken that a perforating typhoidal ulcer docs not escape 
diagnosis. Intussusception will give the characteristic symptoms 
of that condition. 

I have Been cases of lobar pneumonia of the lower lobe of the 
right lung, in which the pleuritic pain radiated down the right 
side into the iliac fossa. There were also epigastric pain and 
vomiting at the onset of the disease. The excessive rapidity of the 
respirations, the marked dyspnoea, and absence of tympanites and 
pain on deep pressure in the region of the appendix, led me to 
examine the lung. 

Prognosis. — Of the 50 hospital cases which I have tabulated 
above, only '■) recovered without operation ; they were of the 



348 DISEASES OF THE GASTRO-ENTERIC TRACT. 

catarrhal variety. These figures give no accurate idea of the pro- 
portion of recoveries made under careful and conservative treatment 
in private practice. 

The mortality in the cases operated upon was 35 per cent. The 
rate is not high considering that many cases came under the knife 
later than would have been the case in private practice. On the 
other hand, it should be remembered that the rate of mortality is also 
influenced by the nature of the infection and the power of resistance 
of the patient. Thus cases with a gangrenous appendix died although 
operated upon on the second day ; others of the same kind recovered 
although the disease had lasted from four to seven days before opera- 
tion. Some perforative cases died on the second or third day of the 
disease, while others recovered although operated upon from six to 
twelve days after the onset of symptoms. Gangrenous cases in 
this statistical table in children show a lower rate of mortality than 
those cases in which the appendix perforates, forms an abscess, and 
causes general peritonitis. 

Chronic Appendicitis. 

This form of appendicitis occurs in older children. The cases 
are frequently mistaken for those of dyspepsia, and vice versa. The 
history is much the same as in the adult. A child otherwise in 
good health has attacks during which there is abdominal pain not 
of great severity, but which may last for a few hours and disappear, 
leaving the patient well. The pain is very rarely referred to 
the appendix ; it is abdominal, the umbilical region being gener- 
ally indicated as the seat of discomfort. The temperature may reach 
100° F. (37.7° C.) ; the pulse in a child of eight years was 96 
and regular. There is no vomiting and no prostration. The pain is 
sufficiently severe to make the patient wish to lie down ; it is not 
excessive when the appendix is palpated. The bowels are regular. 
The cases may in the intervals between the attacks show a slight 
intumescence in the region of the appendix, but nothing is felt in 
the rectum. The signs in the interval may be very indefinite or 
quite distinct. The caecum and appendix are felt to be matted to- 
gether. Three cases in which there had been repeated attacks extend- 
ing over a period of from one to two years, were operated upon for 
me by leading surgeons. The patients were girls between the ages 
of six and eight years. In each case there was evidence of a chronic 
catarrhal process. In one case the appendix contained a fecal cal- 
culus, in another there were constricting adhesions. 

The treatment of both acute and chronic appendicitis in in- 
fants and children does not differ from that followed in the adult 
subject. 



PROLAPSUS ANI. 349 



RECTUM. 



In infants a large portion of the rectum is situated in the abdominal 
cavity rather than in the pelvis. It has three curves — one lateral 
and two anteroposterior. The gut is nearly straight and occupies 
a more or less vertical position, hence the frequency of prolapse. 
The attachment of the rectum to the surrounding parts is not 
extended as high in children as in adults, hence the rectum is more 
liable to be pushed out. The rectum of the newborn infant may 
be divided into three parts. The first lies in front of the sacrum 
and ends at the lower end of the bone ; the second is short, 
and in this respect differs from the adult gut, being also more 
vertical ; the third portion is long, and extends downward and some- 
what backward. The second portion being short, when the rectum 
is distended, the gut is straightened out and the whole rectum 
extends downward and backward (Symington). All these data are 
of importance in applying methods of therapy (enteroclysis, etc.) to 
this organ. 

Prolapsus Ani. 

Prolapsus ani is a condition frequently met with in infants and 
children. It may amount only to an eversion of the mucous 
membrane. There is in some cases a complete descent of part of 
the rectum, which protrudes from the anus to the length of one or 
two inches. 

The etiology of this condition is obscure. It evidently only 
occurs in cases in which the pelvic attachments of the lower bowel 
are lax. It is favored by anatomical conditions elsewhere mentioned. 
It is seen in children who are constipated, in those who suffer from 
diarrhoea, and also in those whose movements are not normal. Any 
abnormal condition in the neighboring organs, such as the bladder 
and urethra (stone), may cause excessive straining and consequent 
prolapse of the gut. A rectal polypus may cause prolapse. 

Symptoms. — In some cases the only symptom is the appearance 
of a small quantity of mucus and blood on the diaper with each 
movement ; in these eases the prolapse returns spontaneously. In 
other cases the bowel descends to the extent of one or two inches 
with the movement, and remains prolapsed. If a polypus of the 
lower part of the rectum is the cause of the prolapse, it is seen pro- 
truding from the prolapsed portion. 

Treatment. — The first step is to replace the protruding gut. 
The <rut i- anointed with olive oil or vaseline and gently replaced 
with a towel. The movements are so regulated by diet and cathar- 
tics that the -tool- are passed without straining. Three times daily 
a suppository containing grains ij to iij (0.12 to 0.2) of tannic acid 
IS placed in the lower bowel. While the movement- are being passed 



350 DISEASES OF THE GASTBO-ENTERIC TRACT. 

the patient is kept in the recumbent posture on a bedpan. This treat- 
ment is frequently successful. In other cases, the buttocks are drawn 
together by adhesive straps and the child is allowed to pass move- 
ments thus strapped. Cocaine and strychnine are used both in sup- 
positories and hypodermically. The protruding portion is painted 
with cocaine. These measures have their failures and successes. 
The only satisfactory method is that first advised — of a strict diet, 
the recumbent posture at stool, and the astringent suppository. The 
Paquelin cautery is sometimes employed to cauterize the mucous 
membrane. The danger in this method is the substitution of a 
traumatic stricture of the anus for the comparatively harmless pro- 
lapse. Application of the pure stick of silver nitrate to the anus 
twice a week, has given good results. If a polypus of the rectum is 
the cause of the prolapse, the growth should be removed by surgical 
means. 

Fissure of the Anus. 

Fissure of the anus is seen in syphilitic infants, in those suffering 
from marked constipation, and in infants that have eczema of the 
anus. It may be the result of the repeated introduction of the hard 
nozzle of an enema syringe. The fissure may be so slight as to be 
only a line-like tearing of the mucous membrane, or may consist of 
a broad ulcer with a hard granulating base. 

Symptoms. — As a rule, the infants are constipated. When a 
movement is passed, the infant cries and there is great pain. A few 
drops of blood are passed on the diaper. 

Diagnosis. — The presence of a fissure of the anus sometimes 
escapes the notice of the physician. If there is a history of the 
above symptoms, the physician should place the infant on a table, 
grasp the buttocks with the palm of the hands and separate them 
forcibly with the thumb. The anus is thus everted, and if a fissure 
is present it will at once become apparent. 

Treatment. — A small fissure is sometimes very successfully 
treated by regulating the bowels. It is touched with a 10 per 
cent, solution of silver nitrate once a day. In the severe cases 
silver applications will not avail ; forcible dilatation of the rectum 
by means of the thumbs must be resorted to. This procedure not 
only cures the fissure, but is also an effectual remedy for the accom- 
panying constipation. 

Spasm of the Anus. 

Cases of nervous spasm of the sphincter ani occur in infants. 
The infant is constipated and cries at each movement. There is no 
bleeding, nor does examination reveal any fissure, but only marked 
contracture of the anal opening. In these cases it is almost impos- 
sible in an examination to bring down the upper part of the anal gut. 



POLYPUS OF THE RECTUM. 351 

The remedy is to regulate the bowels. If by this means success 
in overcoming the spasm is not attained, forcible dilatation is the 
only resource. 

Proctitis. 

Apart from the membranous and catarrhal forms of proctitis, 
which occur with similar conditions of the intestine, the only form 
which is of interest is the gonorrhoeal. This occurs as a complication 
of vulvovaginal gonorrhoea! inflammation. In these cases the in- 
troduction of the gonococcus from the vagina into the gut has 
occurred through careless thermometry or the giving of enemata 
without previous cleansing of the parts. The disease is very pain- 
ful and at the same time trying to the infant or child. With the 
discharge of pus from the anus there are tenesmus and a bloody 
discharge with the movements. The purulent discharge shows 
gonococci. 

The treatment consists in the injection of protargol solutions, 
2 per cent., at a temperature of 105° to 108° F. (46.5° to 42.5° C), 
into the rectum twice daily. The bowels are regulated. Supposi- 
tories of tannin or tannigen are also of value and give great relief; 
one containing grains iij (0.18) is given per rectum twice daily. 
In the later stages it may be necessary to paint the lower bowel 
with a very weak solution (0.5 per cent.) of silver nitrate. 

Polypus of the Rectum. 

Polypus of the rectum is not rare in childhood, but is not often 
seen in infancy. It occurs most frequently from the third to the 
seventh year of life. The polypi are adenomata. I have examined 
several, and have found them to have the structure described by 
Baginsky. They may be single or multiple, usually have a pedicle, 
but may be attached to the wall of the gut by a broad base. As a 
ride they are situated <>n the posterior wall of the rectum seven or 
eight centimetres above the anal ring, but may be on the anterior 
wall. In most eases the polypi exist here only, but I have seen 
them higher up in the gut, and in one ease in a child of five years 
from whom several rectal polypi had previously been removed, I 
diagnosed a number in the descending colon. In this case lapa- 
rotomy and incision of the gut proved the diagnosis to have been 
correct. The polypi may, if they become numerous, assume a 
malignant character: this Is especially true of the growths with a 
large, broad intestinal bafi 

Symptoms. — The characteristic symptom i- intermittent hemor- 
rhages from the gut, which may be profuse. At times the outer 
surface of the movement- is Streaked with blood, the bowels being 
constipated or normal, with an occasional mucous diarrhoea. If the 



352 DISEASES OF THE G ASTRO-ENTERIC TRACT. 

polypus is low down, there is straining at stool with prolapsus of 
the gut. Many of the children thus aifected are pale, have a pasty 
hue of the skin, and show evidences of lymphatism. 

Diagnosis. — Bleeding from the bowel, in the absence of other 
symptoms, should at once suggest the- necessity of digital explora- 
tion of the lower bowel. If a polypus is not found, a careful pal- 
pation of the abdomen made when the patient is fasting should be 
the next procedure. If the child is tractable and the abdomen soft, 
it may be possible to feel a tumor of the size of a hazelnut at one 
side of the umbilicus. 

The prognosis is good ; removal of the polypi is rarely followed 
by recurrence of symptoms, even in cases in which they are situated 
in the descending colon. If they are removable and not very 
numerous, the patient recovers. 

Treatment. — If the polypus is low down and pedunculated, it 
may easily be snared with or without the aid of a rectal speculum, 
and crushed or ligated off. If it is high in the sigmoid flexure, the 
anus should be dilated and the growth reached by means of a specu- 
lum. In cases in which the growth is in the colon, laparotomy, 
enterotomy, and ligation are indicated. 



INTESTINAL PARASITES. 

The most common parasites found in infants and children are 
the Nematoda, or round worms, and the Cestoda, or tapeworms. 
The round worm is smooth and light brown or reddish in color, 
the female being larger than the male. The eggs are found in the 
stools ; they are from 0.05 to 0.06 mm. in diameter and are sur- 
rounded by an albuminous envelope. The worm is several inches 
long. Oxyuris vermicularis is about 1 cm. long, the male having 
a length of 4 mm. The eggs measure 0.05 mm. in their long 
diameter. 

The tapeworms in mature state consist of rectangular segments. 
The head and neck are called the scolex ; the segments, proglottides. 
The worms are hermaphrodites. The solium is sometimes several 
metres long. The head is of the size of a pin's head, with a pro- 
jecting proboscis armed with booklets. The eggs of the solium are 
ovoidal, 0.3 mm. in diameter. The Taenia mediocanellata has a 
more cuboidal head without hooklets (Fig. 94). 

Diagnosis. — There are no symptoms which can be traced to the 
presence of these worms in the gut. If they increase in enormous 
numbers, they may cause symptoms of mechanical obstruction. 
Without the presence of the eggs or links of the worm, a diagnosis 
is not possible. Their presence is made known by the passage per 
anus of the links of such worms as the tapeworm. Round worms 



ROUND WORMS. 



353 



may also pass out of the anus, or may be vomited if they gain 
access to the stomach. Thread worms may cause excessive pruritus, 
and may not be discovered external to the anus. In that case the 
feces should be carefully examined for the eggs of the worms. 

Fig. 94. 






BtaSMMSK^imiBI 



PMBffl 



1. Oxyuris vermicularis, pin worm, natural size. 

2. Egg of Ascaris lumbricoides. 

3. Egg of Oxyuris vermicularis, pin worm. 

4. Egg of Trenia solium. 

5. Proglottides or links of Taenia solium. 

6. Proglottides of Bothriocephalus latus. 

Round Worms. 

( .-I .sea r i c/e.s Lum brim i< It «. ) 

This parasite is found in the small gut ; it may invade the stomach 
or may pass downward into the rectum. Cases are recorded (Borger; 
in which it has passed into the bile-duct and caused abscess of the 
liver. There may be only one or many of these worms in the 
gut. Leuckart states that they may form large masses in the gut, 
and thus cause intestinal obstruction. They have been known to 
perforate the gut and cause peritonitis. The eggs are introduced 
into the gut through the medium of drinking-water, fruit, and vege- 
tables. Epstein cultivated the eggs outside of the body and then 
introduced them into the gut, where they developed. The male 
worm is 250 mm. long, the female being longer. 

The symptoms caused when these parasites have once gained 
access to the body are not characteristic. I have seen the worms 
passed or vomited by children apparently in normal condition. 

The treatment consists in placing the patient on a milk diet. 
After a few day- the following powder is administered two or three 
times dailv : 



Calomel, 

Santonin ail gr. 



(0.01(5). 



Santonin i- sometime- administered in the form of* pastiles, but i4 
not more satisfactory than the above preparation. 



354 DISEASES OE THE G ASTRO-EX TERIC TRACT. 

Oxyuris Vermicularis. 

(Pin Worm; Thread Worm.) 

Brass showed that the habitat of these worms is the small intes- 
tine, whence they pass into the caecum. The female worm lays its 
ova in the folds of the gut. They may pass into the stomach and 
thence into the mouth, but more frequently pass out of the anus 
into the vagina or into the prepuce and urethra. They exist in 
enormous numbers in the gut, are exceedingly small, and have 
the appearance of fibres of cotton fabric. They can be seen by 
spreading the nates apart. They are then found in the anus, or in 
female children in the fourchette. The principal symptom is intol- 
erable pruritus, so intense as to deprive the children of sleep. This 
worm is found only in the human subject. It is conveyed from 
person to person through uncleanliness. The larva? adhere to the 
fingers, and thence are introduced into food-stuffs. 

Treatment. — It is a very difficult task to dislodge these worms ; 
injections by the rectum cannot reach those higher in the intestine. 
The plan which I have followed, and which gives relief, is to give 
daily enemata of quassia wood before bedtime : 

Quassia wood (ground) 3j (31.0). 

Aquae dest Oj (500.0). 

Make an infusion and strain. 

I have in addition utilized the prescription of santonin and calomel 
given above for the round worms. 

Schmitz recommends the administration of naphthalin, grains 
j to iij (0.06 to 0.18), t. i. d., for a week, after which it is discon- 
tinued for a few days, and then given again. 

Tapeworm. 

(Taenia.) 

Taenia are quite common in children, and have been found in the 
newly born infant (Muller and Armor). In these cases the eggs 
must have been deposited in the liquor amnii, and thus swallowed 
by the foetus. Numerous cases have been recorded of the presence 
of these worms in infants from the third to the twelfth month. 
They are most frequently found between the first and the third year. 
The varieties most commonly found in children are : Taenia solium, 
Taenia mediocanellata, Taenia elliptica, Bothriocephalus latus. 

Sources of Origin. — Taenia Elliptica. — The lice of the house-dog 
and cat are introduced by the fingers of the children into their 
mouths, and thus gain access to the gut. There the larvae of the 
tapeworm Avhich they contain develop. 

Taenia Solium. — The larvae of this worm are found in badly 
cooked pork or beef. 



TAPEWORM. £55 

Taenia Mediocanellata. — The Larvae of this worm are found in 
beef. Bothriocephalus latus is introduced by the ingestion of in- 
fected fish-food. 

The Larvae of tapeworm may exist in the flesh of the hare, pigeon, 
pheasant, chicken, goose, or duck. Ice if made from infected 
water may be a means of introducing the larva? in the body. It is 
thus not necessarily the meat-eating children who run the danger of 
swallowing the larva? of tapeworm ; milk if diluted with infected 
water may contain them. 

Symptoms. — Tapeworms may exist for months or years in the 
body of a child without causing untoward symptoms. As many as 
three varieties of the worm have been found in the same child. 
The symptoms are not characteristic. The passage in the move- 
ments of the links of the taenia is the only positive evidence of 
their presence. 

Treatment. — The only successful treatment for the expulsion of 
the tapeworm is that which consists in the administration of filix 
mas in some form. It should be freshly prepared and given in 
liberal doses : Ext. seth. filix mas, Tftxxx (2-0) to 3j or ^ij (4.0 
or 8.0), is made into an emulsion with gum tragacanth, and mixed 
with equal parts of castor oil. The administration of this mixture 
is preceded by a day or more of milk diet. The child is then given 
from half a drachm to a drachm (2.0 to 4.0) of the filix mas with 
castor oil in divided doses. The recumbent posture is maintained 
in case nausea should be experienced. The movements containing 
the worm are carefully washed through a sieve, and the smallest part 
of the worm sought for in order to see if the head has come away. 

The patient should be given a drawing of the comparative size 
of the head and links of the worm, in order that the head may not 
be lost, or the physician may seek it himself. 

Leading Authorities Referred to in Chapter V. 

Amkerg, S. : M A Contribution to Amoebic Dysentery." etc, Johns Hopkins Bull., 
December, 1901. 

Borger, Q.: " Ascaris Lumbrieoides," etc., Arbeit, aus rler k univ. Kinderlinik, 
Munich, 1891. 

Biedert, V. : Diatetische Behandlung der Verdaunngs storungen, Stuttgart, 1901. 

Booker, Win..- "A Bacteriological and Anatomical Stud j of the Summer Diar- 
rhoeas," etc., Johns Hopkins Hospital Rep., vol. v. 

Beck, Carl: "Appendicitis," Vblkmann's Vortrage, No. '1'1\. 

Czerng an'1 Keller: Ernahrungstdrnngen, 1901. 

Epstein, A. : M Beobachtungen fiber Afonocercomonas," etc., Prager nied. 
Wochen., 1893. 

<>/,, T. : Streptokokken Enteritis, Jahrbuch. f. Kinderheilk., Bd. WAX. 

Dysenteric," CentralbL f. Bakt, 18 

" .Ktiol. der Primaren ac. Bfagen I)arm Krankheit," Wien. med. Wochen., 

Filatow, X. : Darmkatarrh der Kinder. Vienna, 1893. 

/.. : " One Thousand Operations for Acute [ntestinal Obstruction," 
Annal> of Sorgerj, L900. 



356 DISEASES OF THE GASTRO-ENTERIC TRACT. 

Gregor : Fettgehalt der Frau en milch, etc., Volkmann, 1901. 

Heubner, 0.: " Atrophie," Jahrbuch. f. Kinderheilk., N. F., liii. 

Gedeihen u. Schwinden, Berlin, 1898. 

Leuckart, R. : Die Parasiten des Menschen, Leipzig, 1894. 

Marfan, A. B. : Gastro-enterites des Nourissons, Paris, 1900. 

Traite de V Allaitement, Paris, 1899. 

Morse, J. L. : "Renal Complications of Acute Enteric Diseases," Trans. Amer. 
Ped. Soc, 1899. 

Nicoll, I. H. : " Congenital Stenosis of the Pylorus," Pediatrics, 1901. 

Pf'aundler, M. : Ueber Stoffwechsel Storungen, Berlin, 1901. 

Magen Capacitat, etc., Bibliotheca Medica, Stuttgart, 1898. 

Pritchard, E. : " Congential Pyloric Stenosis," Arch, of Ped., 1900. 

Spiegelberg, I. H. : Arch. f. Kinderheilk., Bd. xxvii. 

Thomson, John : "Congenital Hyper, of the Pylorus," Edinburgh Hospital Rep., 
1896— Scott. Med. and Surg. Jour. ? 1897. 

Treves, F. : Intestinal Obstruction, New York, 1900. 

Vallee, P. II. : Situation du Ccecum, These, 1900. 



CHAPTER VI. 

DISEASES OF THE RESPIRATORY TRACT. 
GENERAL CONSIDERATIONS. 

The normal number of respirations in infants and children is as 

follows : 

Immediately after birth 44 per minute. 

From the first to the sixth month 24 to 36 " " 

From the second to the fifth year 20 to 32 " " 

From the sixth to the tenth year 20 to 28 " " 

The ribs of some infants are very apparent to the eye, while in 
others they are so covered by a panniculus of fat as not to be seen. 
The normal chest has not the shape which it assumes later in life — 
that of a truncated cone. The lateral portions are quite straight 
and parallel. The chest is not flattened anteroposteriorly to the 
same extent as in the adult. In the newly born infant the trans- 
verse diameter is twice the length of the anteroposterior, while in 
the adult it is three times its length. In infants the superior 
border of the manubrium sterol is on a level with the mid-section 
of the first dorsal vertebra. In the adult it is lower by a body and 
a half of a vertebra. 

The tendon of the diaphragm is horizontal in the newly born 
infant, and is on a level with the disk between the eighth and the 
ninth dorsal vertebra. 

A rachitic chest may be conical anteriorly at the sternum (chicken 
breast). Some rachitic chests show a marked flaring of the lower 
ribs, with an incurvation above at the sides ; they are flattened at 
the >ides and taper toward the sternum. The sternum is the top of 
the truncated cone. Infants and children who have had several 
attacks of bronchitis, and who have some emphysema, show a 
marked fulness at the upper part of* the chest beneath the clavicle-. 

Skoliosis of the spine may deform the chest, giving undue promi- 
nence to one side. Retraction occurs after the absorption of pleuritic 

effusions. 

Movements of the Chest. — The movement- of the chest may 
normally be irregular in rhythm ; the sides move symmetrically. 

In disease, especially in condition- of pressure on one side of the 
Deck, one side of the chest may remain immobile, the other being 
retracted with each respiration to an exaggerated degree. I have 

357 



358 DISEASES OF THE RESPIRATORY TRACT. 

observed this condition after operations for retropharyngeal abscess 
in the neck, in cases in which the nerves in this region were pressed 
upon or injured, thus interfering with the normal action of the dia- 
phragm. 

In effusion into one side of the chest, there is diminished motion 
on the diseased side. Emphysema may restrict the normal move- 
ments. 

Cheyne-Stokes respiration is seen in cerebral disease. After a 
deep and full inspiration the respirations become increasingly shallow 
until they are scarcely perceptible. A deep inspiration is then taken, 
and the respirations become more and more marked in the ascending 
scale, finally reaching the original force and depth. The cycle is 
then repeated. 

In forms of pleurisy with effusion the intercostal spaces are re- 
tracted more than is normal at each descent of the diaphragm. This 
may be due to adhesions. The precordial region may be drawn in- 
ward with the recoil of the heart, as is sometimes seen in adherent 
pericardium. 

Fremitus. — The method of obtaining fremitus in children is 
described on page 24. It may be mentioned here that fremitus is 
well marked normally in the posterior axillary line and in the inter- 
scapular region. 

The Normal Limits of the Lungs. — In the mam miliary line on 
the right side to the sixth rib ; in the mid-axillary line to the ninth 
rib. Posteriorly on the right side to the tenth rib ; on the left side 
to the eleventh rib. Thus the limits are practically the same as in 
the adult subject (Symington). 

The amount of lung-tissue above the clavicle cannot be mapped 
out in infants and children. 

Resiliency of the Chest-wall. — The chest-Avail in infants and 
children has a normal resiliency to percussion. The wall gives 
beneath the finger. This is a definite feature. In any disease of 
the chest which interposes fluid between the chest-wall and the lung 
this resiliency of the wall is absent. In infants and children, as in 
adults, there are normally : 
Pulmonary resonance ; 
Dulness varying to flatness ; 
Tympanitic resonance. 

Pulmonary resonance is lower in pitch than in the adult. Ante- 
riorly over the right infraclavicular region it is less marked than on 
the left side ; the note is also slightly higher and of shorter duration. 

Dulness is found normally over the heart, liver, and spleen ; also, 
(interiorly on the right side from the fourth to the sixth rib. From 
the sixth rib to the borders of the ribs the note is flat. In the mid- 
axillary line on the right side there is dulness from the fifth to the 
seventh rib ; from this point to the free border, the note is quite flat. 



GENER . 1 L CONSIDER A TIOSS. 



359 



On the left side at the level of the sixth rib, just above the spleen, 
there is a narrow strip ot' relative dulness, due to the presence be- 
neath the diaphragm of the left lobe of the liver (Fleischman) (see 
Spleen). 

Fig. 95. 




Strip of relative d ribed by Fleischman, and found jusl above the spleen, supposed 

to be due to the presence of the bit lobe of the liver, child, two years oJ 



Posteriorly the supraspinous regions give dulness, but not so 

markedly as in the adult. On the right Bide, from the level of the 
Seventh dorsal vertebra, extending downward, there is dulness due 
to the liver. 

Tympanitic resonance due to the stomach i- found normally in 
the left axillary line. It may in some cases extend high up in the 
axilla. 

Auscultation. — As a rule, there is little difficulty in obtaining 



360 DTSEASES OF THE RESPIRATORY TRACT. 

the respiratory murmur and voice-sounds in infants and children — 
certainly not in the latter. The crying of unruly infants is useful 
in that it gives the fremitus and the quality of the voice-sounds. In 
some cases the infants are very quiet during examination, and un- 
less they are teased into crying, definite information on these points 
cannot be obtained. The infant is caused to cry by gently squeezing 
the cheeks with the thumb and index finger. 

The Breathing. — The respiratory sounds in infants and children 
are of an intensified vesicular quality ; this so-called puerile breath- 
ing is normal and constant in children under twelve years of age. 
The quality of the vesicular murmur is probably caused by the 
better conducting qualities of the chest at this age. The elasticity 
of the lungs, which causes greater resistance to the inspiratory dilata- 
tion, is also a factor in producing the puerile quality of the respira- 
tory sounds (Gutman). 

Types of Puerile Breathing. — Puerile breathing in infants and 
children may be classified as follows : 

a. The most common type is that in which the inspiration is 
coarse or intense in quality, while the expiration is vesicular and 
almost inaudible. 

b. The second type of puerile breathing is that in which the in- 
spiration and expiration are both of an intensified coarse quality. 

c. The third type is that in which the inspiratory sound is low 
and vesicular, and the expiratory, coarse and puerile. 

These types are found in infants and children at rest. If they 
are caused to cry, both the inspiratory and the expiratory murmur 
are of a coarse puerile quality. In some infants and children at 
rest, the inspiration and expiration are vesicular as in the adult. 
Puerile breathing is frequently confounded with bronchial breathing. 
It is, however, never tubular in quality. Bronchial or tubular 
breathing is marked on expiration ; puerile breathing is generally so 
on inspiration. 

During auscultation the sides of the chest are always compared. 
On the right side, beneath the clavicle and over the spine of the 
scapula, the expiratory murmur is more intense than on the left side. 
This should be especially remembered in cases in which disease 
of the right apex is suspected. The quality of the breathing in 
these regions approaches the bronchovesicular. 

Posteriorly, the respiratory murmur may be heard as far down as 
the level of the eleventh dorsal vertebra. In some children the 
sounds are not so intense toward the base of the lung behind as 
higher up in the chest. 

Bronchovesicular breathing is heard normally in the interscapu- 
lar region in children as in adults. It has the same qualities as in 
the adult. 

Bronchial breathing is heard normally over the trachea and upper 



GENERAL CONSIDERATIONS. 361 

part of the sternum. It is also called tabular, tracheal, and over 
the larynx, laryngeal breathing. 

Forms of Dyspnoea. — Though mainly of two types, pulmonary 
and laryngeal, dyspnoea may be caused by pain, fever, cardiac dis- 
ease, and abdominal tumors. 

Pulmonary Dyspnoea. — There is not only an increase in the num- 
ber of respiratory movements, but also a change in the depth of 
each respiratory effort. In the dyspnoea of pulmonary disease, the 
region at the border of the ribs adjacent to the abdominal walls 
( peripneumonic groove) is drawn forcibly inward at each inspiration. 
In emphysema with asthmatic attacks, it will be noticed that during 
the attack the upper part of the thorax is immobile, the inferior part 
being drawn inward with each inspiratory effort. The presence of 
fluid in one side of the chest may be suspected if the side remains 
immobile, or if the intercostal spaces are drawn inward with each 
forced inspiration. A splenic or nephritic tumor may also, by simple 
upward pressure, immobilize one side of the chest. 

Laryngeal dyspnoea will occur in any obstructive disease of the 
larynx. In addition to the phenomena of the pulmonary form of 
dyspnoea, there is a distinct retraction of the tissues at the situation 
<>f the suprasternal notch. There may also be laryngeal or croupy 
breathing. 

While this is true in the majority of cases, I have also seen 
the retraction of the suprasternal notch, described above, pres- 
ent in the later stages of severe forms of acute pulmonary disease, 
especially in children ; also in cases of emphysema in the asthmatic 
attack. 

Pain will cause an increase in the number of respiratory move- 
ments. Thus the pain of an incipient pleurisy will cause an increased 
number of respirations which are more shallow than is normal. 
Peritonitic pain will also cause the respirations to become shallower 
and to increase in number. 

Fever will, especially in infants and children, increase the number 
of respiratory movements to 40 or more, without the presence of any 
lung disease. 

Cardiac dyspnoea is Been in those diseases of the heart which 
cause a retardation of the pulmonic circulation. The aeration of 
the blood in the capillaries of the lung is considerably interfered 
with under these condition-. Mitral disease, stenosis, and regurgi- 
tation cause dyspnoea not only for the reason given above, but also, 
in the later stages, on account of the bronchitis which is the result 
of the cardiac disease. Anaemia of cardiac disease is also accom- 
panied by a -light dyspnoea, which is especially marked in children. 
The slighte-t exertion will sometime- cause angina and dyspnoea in 
children suffering from a -light cardiac Lesion. 

Ascites and abdominal tumors, or enlarged organs, such a- the 



362 DISEASES OE THE RESPIRATORY TRACT. 

liver or spleen, will cause dyspnoea, especially when patients are in 
the recumbent position. 

In weak infants a few days old, who are the subjects of atelectasis 
and pneumonia, the upper part of the chest-wall moves very little, 
while the inferior portion of the chest and the upper part of the abdo- 
men ^peripneumonic groove) are drawn inward at each inspiration. 



ACUTE SIMPLE BRONCHITIS. 

Bronchitis, acute and simple, is an affection of the larger and 
medium-sized bronchi. In very young infants the disease is apt 
to be very severe and to attack the smallest bronchioles ; it is then 
called capillary bronchitis. A capillary bronchitis is really a bron- 
chitis in which there is a certain amount of peribronchitic pneu- 
monia. Acute bronchitis may occur at any period of infancy or 
childhood. It is, however, less common before the sixth month 
of infancy than during the period up to the third year, when its 
frequency diminishes. 

Causation. — Bronchitis may be caused by an exposure to cold 
or wet or by traumatism to the mucous membrane of the air-pass- 
ages through the inhalation of dust or irritating vapors. It occurs 
in the acute infectious diseases, such as malaria, scarlet fever, 
measles, rotheln, varicella, typhus and typhoid fevers, and frequently 
complicates pneumonia of the lobular or lobar type. Rachitis and 
syphilis predispose to attacks of bronchitis. The bronchitis of 
heart disease or nephritis should be regarded as of a different class. 

Pathology. — The bronchi may be filled with a mucous, serous, 
purulent, or mucopurulent secretion, which is secreted by the epithe- 
lium of the mucous membrane and the mucous glands in the wall 
of the bronchi. In recent acute bronchitis the mucus is quite 
abundant. In the exudate on the mucous membrane of the bronchi 
and in the lumen, epithelial cells, leucocytes, and sometimes red 
blood-cells are found. The structure of the mucous membrane is 
infiltrated with small round cells to a greater or less degree. In 
some places the epithelial lining of the bronchi may be raised by 
exudate ; in others there may be loss of the superficial epithelium. 
If the bronchitis lasts any length of time, there may be atrophy of 
the structures of the mucous membrane. In the severer forms of 
bronchitis which affect the smaller bronchi the peribronchitic con- 
nective tissue is infiltrated with small round cells. In these cases 
there is an inflammatory exudate in the surrounding alveoli of the 
lung. There is then peribronchitis or bronchopneumonia. 

Symptoms. — In some cases the infant or child suffering from 
acute bronchitis will have a simple angina as an initial symptom. 
There is mild redness of the fauces with a slight rise of temperature 






ACUTE SIMPLE BRONCHITIS. 363 

which may last a day or more. The cough which was present at 
Hrst persists, and there may be slight disturbance of the bowels, the 
movements being green and containing large curds of undigested 
matter. 

The cough may in aggravated cases give rise to occasional at- 
tacks of vomiting, especially immediately after nursing; at other 
times the coughing spells may cause the patient to cry. There 
is evidently pain, especially in the cases of bronchitis affecting 
the larger bronchi. The infant sometimes suffers from great 
difficulty in expelling the accumulated secretion. The attacks of 
coughing closely resemble those seen in old people who suffer from 
bronchitis. In many eases the infant or child is quite comfortable 
in the intervals between the coughing spells. In others the respira- 
tions are increased, and there may for some days be a slight evening 
rise of temperature, the patient showing signs of being seriously ill. 
In very young infants who are rachitic there may be a distinct 
drawing in of the sides of the chest and of the peripneumonic groove 
at each respiration. In eases of severe involvement of the smaller 
bronchi, there may be slight cyanosis of the lips and pallor of the 
surface. 

In the severer forms of bronchitis, especially of the grippal 
variety, there is a distinct rise of temperature for several davs. It 
may rise to 102°-103° F. (38.8°-39.4° C), or even higher,' with a 
corresponding increase in the number of respirations and the pulse- 
rate. In weak and very young infants there may be little or no 
cough. The infant lies in a soporose state, does not nurse well or 
refuses the breast. Older children may run about and play while 
suffering from bronchial trouble ; severe bronchial disturbance may 
appear to have little effect on the general health. Expectoration is 
very exceptional ; a frothy mucus collects about the lips of young 
infants after an attack of coughing. In older children it may be 
very difficult to collect sputum, even if they are old enough to un- 
derstand the necessity of expectorating the secretion. The conclusion 
has been that children swallow the expectoration ; it is more rational 
to suppose that the efforts at coughing are not equal to raising any 
considerable quantity of secretion or that the amount of secretion 
in bronchitis is not so great as has been generally supposed. In 
many cases the cough i- severer at night than during the day, but 
children cough and fall asleep immediately afterward, and therefore 
do not lose much rest. I have never met with a simple acute bron- 
chitis ushered in by a chill or convulsion. I have, however, seen 
severe forms of bronchitis cause petechial extravasations on the 
skin, similar to those -ecu in pertussis. The petechia are apt to 
occur alx.nt the forehead and eyes of very weak infants. 

Physical Signs. — In mild cases the respirations may be slightly 
above the normal ; in severer cases there are signs of dyspnoea and 



364 DISEASES OF THE RESPIRATORY TRACT. 

the respirations are increased in number. In very severe forms the 
peripneumonic groove may be drawn inward with each respiratory 
act. In capillary bronchitis the lips may show some cyanosis, the 
surface may be pale, and the finger-tips slightly cyanosed. 

Palpation. — If the palms of the hands are placed in front and 
behind the chest, the so-called rhonchal fremitus may be elicited. 
The vibrations caused by accumulated secretion in the large and 
small bronchi give a sensation resembling that felt in stroking a 
purring cat. 

Percussion. — In simple acute bronchitis, percussion may elicit 
nothing abnormal. If infants have suffered from repeated attacks 
of bronchitis, the note may, owing to a slight emphysema, be hyper- 
resonant or vesiculotympanitic. In severe forms of capillary bron- 
chitis there may be areas of peribronchitic pneumonia or broncho- 
pneumonia, over which careful percussion will detect slight dulness 
with a resonant note. 

Auscultation. — In a vast number of cases, bronchitis at the outset, 
gives on auscultation nothing but a rude respiratory murmur which 
is more markedly puerile than is normal. As the secretion accumu- 
lates there will be sonorous, sibilant, and subcrepitant rales, and also 
sonorous breathing. In the form called capillary bronchitis, with 
the subcrepitant rales there will be rales of much finer quality, re- 
sembling crepitant rales. The latter, which are unmistakable, are 
heard on inspiration, and appear to indicate areas of peribronchitic 
pneumonia. In newly born and weakly infants there are, in this 
form of bronchitis, areas in which the air is not heard to enter the 
lungs (atelectasis). 

The treatment of simple acute bronchitis should be supporting 
and expectant. If the cough is harassing, a mild opiate mixture in 
combination with a small quantity of ipecac may be given. The 
following prescription has been found useful : 

R Tinct. opii camph 3j (4.0). 

Syr. ipecacuanhas .. . Tr\, xxxij (2.0). 

Syr. tolutaui ^ij (60.0). 

Sig. Teaspoon I'ul every three hours. 

The patients are allowed to be in the open air in fine weather, and 
the room should be well ventilated at night. In cases in which there 
is great relaxation of the mucous membranes, a dose of strychninse 
sulph., grain -^\-^ (0.0003), may be given three or four times daily. 
The child is kept warmly clad, and wool is worn next the skin. 
Douching with cold water is to be avoided in acute cases. The oil- 
silk jacket may be worn, but it has no special superiority to warm 
clothing. Applications of oil to the chest are of no value. The 
drugs of the coal-tar series (antipyrin or phenacetin) should not 
be used, except that one dose may be given at the very outset to 



FIBRINOUS OR PLASTIC BRONCHITIS 36 o 

relieve restlessness or headache. The bowels should be relieved by 
means of calomel or a saline cathartic. 

In the subacute stage, syrup of ferric iodide may be given as a 
tonic for the mucous membrane. In very rachitic infants and chil- 
dren, cod-liver oil is indicated. 

The treatment of so-called capillary bronchitis approaches very 
closely that of bronchopneumonia. The heart should be supported. 
Digitalis in the form of tincture is the most useful remedy. Strych- 
nine, caffeine, camphor, and musk in form of powder, all have here 
their legitimate sphere. 

The temperature, as a rule, needs no treatment. With older chil- 
dren, if the secretion is very profuse, carbonate of guaiacol is exceed- 
ingly useful and gives much relief. 



FIBRINOUS OR PLASTIC BRONCHITIS. 

This is a form of bronchitis in which membranous masses or 
fibrinous exudate are coughed up at intervals. These masses may 
have the exact shape of the bronchi, or may consist of shreds or 
bands of membrane. 

Etiology. — Bronchitis of this form complicates diphtheria and 
pneumonia, and also occurs in the acute infectious diseases — measles, 
scarlet fever, tuberculosis, erysipelas, typhus and typhoid fevers. 
It is found in diseases of the heart and lungs, and may result 
from traumatism through the inhalation of poisonous gases. The 
above are the secondary forms ; the primary form of fibrinous 
bronchitis is obscure in its etiology, and is rare in infancy and child- 
hood. 

Morbid Anatomy. — The casts which are coughed up are cylin- 
drical in shape and branched in the form of the larger and smaller 
bronchi. The larger one- may be hollow and cylindrical, while the 
smaller ramifications may be solid or thready. In other cases the 
whole cast is solid ; small air-bubbles may be confined in the fibrin- 
ous cylinders. The casts may be 10-12 cm. in length, the extremi- 
ties being nodnlar, thready, or flat. Under the microscope the casts 
are seen to be formed in Layers ; in the centre of the oldest layers are 
found epithelium of the bronchi, leucocytes, and bacteria. Spirals 
formed of fibrin are occasionally found in the expectorated masses, 
ially in the diphtheritic, pneumonic, and the so-called idiopathic 
cases. 

Symptoms. — Attacks of Dyspnoea. — This Form of bronchitis is 
characterized by attack- of dyspnoea and coughing. During the 
attack.- clot- of purulent fibrinous masses are expectorated, some- 
times with a slight amount of blood. In spite of the expectoration 

ot* blo.xl there are no signs of tuberculosis. The presence of blood 



366 DISEASES OF THE RESPIRATORY TRACT. 

is probably caused by the detachment of the membranous casts from 
the walls of the bronchi. The expectorated masses may contain 
asthma crystals. In the intervals between the attacks, there may 
be symptoms of an ordinary bronchitis with mucopurulent expecto- 
ration, or there may be absolute freedom from symptoms. 

The cough, which is present during the attacks, may be accom- 
panied by a snarling or fluttering sound. 

Cyanosis may be present during the attack to a marked degree or 
may be absent. 

Fever is present in the acute form, but has no special character- 
istics. 

Splenic tumor may be present. 

The physical signs of bronchitis may be present with rales of 
all kinds. If the membranous masses hang detached in the bronchi, 
a snarling or flapping sound may be heard on auscultation. 

The general condition of patients in the intervals and during the 
attacks varies greatly. In some cases it is fairly good. 

Complications. — A tuberculous bronchitis or pneumonia may be 
a complicating condition. 

The diagnosis is made from the presence of the fibrinous casts. 

The treatment has thus far been very unsatisfactory ; mercury, 
and also inhalations and sprays of all kinds have been tried by 
Biermer in the acute cases. Iodide of potassium is of value in the 
intervals. If diphtheria is present, the antitoxin is given. 



EMPHYSEMA AND CHRONIC BRONCHITIS OF THE 

LUNGS. 

Frequency. — Emphysema is a condition frequently seen post- 
mortem in the lungs of infants and children (Steffen). No dis- 
ease of the lungs runs its course without causing some emphy- 
sema. The condition is much more common in children than in 
adults, because it is favored by the peculiar structure of the lung 
during early life. Most of the forms of emphysema of the lungs 
of infants and children retrograde, allowing the lung to return to 
its normal state. Otherwise emphysema would be more common in 
adult life than it is. Clinically, emphysema combined with various 
forms of pulmonary disturbance, especially bronchitis, is very com- 
mon in infants and children. My experience in this respect confirms 
that of Steffen and Osier. It seems to be common to certain classes 
of children, especially those of rachitic tendencies. 

Morbid Anatomy. — Steffen has made a very careful study of 
the pathological condition in emphysema of the lungs of infants 
and children. The thorax has not the typical barrel shape seen in 
the adult, and occasionally found in older children. In younger 



EMPHYSEMA AND CHRONIC BRONCHITIS OF THE LUNGS. 867 

children,' especially in those with rachitis, the sides of the lower por- 
tion of the thorax are incurved ; tin 4 upper part of the thorax in 
front underneath the clavicles may be full and prominent. On open- 
ing the chest, the lungs are found to be inflated, to retain their form, 
and to show along the situation of the ribs a scries of indentations 
due to pressure. The depressed portions may be denser than those 
raised, and show area- of circumscribed persistent pneumonia. In 
vesicular emphysema, air-vesicles may rupture into one another, 
giving rise to large sac-like formations which communicate with a 
bronchus. Some of the air-vesicles may rupture into the subpleural 
tissue. Vesicular emphysema rarely involves a whole lung or 
both lungs, but is localized to certain areas, such as the apices, 
anterior borders, or the lingula. The emphysematous areas are 
whitish, yellowish white 1 , or reddish yellow, the color varying with 
the amount of blood contained. They are raised above the surface, 
are elastic and velvety to the touch, and crepitate with the air con- 
tained. In children, in contrast to the condition in the adult, the 
heart is rarely dilated, and the liver and kidneys rarely affected. 
This is due to the temporary nature of the process. Bronchitis, 
trachitis, and laryngitis may exist as primary or secondary condi- 
tions. It is not possible to consider emphysema in infants and chil- 
dren as an isolated condition. Since it is most frequently seen in 
pronounced bronchial affections, it will be convenient to consider it 
in connection with bronchitis. 

Symptoms. — Some infants and children suffer from a chronic 
catarrhal bronchitis which is more or less present at all times, and 
which may be interrupted by attacks of acute bronchitis. Infants 
and children thus affected are more or less rachitic ; some have 
lymphatism in the form of chronic hypertrophic rhinitis and also 
adenoids or enlarged tonsils. In the intervals between the attacks 
of acute bronchitis, the patients do not seem to suffer much con- 
stitutional disturbance. There is no fever, and no change in the 
respiration except that it assumes a noisy character. There is a 
cough which comes on at intervals, especially at night. The infants 
arc pale, with rather flabby muscles, and may be fat, but impress the 
physician as being below the normal in point of strength. 

Physical Signs. — If the bronchitis has persisted a long time, 
the upper part of the chesl i-. even in infanta under the age of twelve 
month-, abnormally lull. The upper costosternal region is high 
and the intercostal spaces are filled out. In milder eases there are 
no signs to be detected on inspection. 

Palpation. — There i- distincl rhonchal fremitus felt anteriorly and 
posteriorly. 

Percussion. — If there have been a number of acute attacks, there 
will be emphysema of a vesicular type, giving a hyper-resonant 
note. In pronounced rachitis the hyper-resonance is apt to be 



368 



DISEASES OF THE RESPIRATORY TRACT 



marked. The area of relative cardiac dullness in older children 
is much diminished (Fig. 96). 

Auscultation. — Voice-sounds are normal. The breathing is rude 
or sonorous. The respiratory murmur may be prolonged. There 
are sonorous, mucous, and subcrepitant rales. 

A. second set of cases of chronic bronchitis comprises those in 
which a condition of pronounced emphysema of a vesicular charac- 
ter is present, and in which there are distinct attacks of dyspnoea or 
asthma. These cases must be differentiated from the purely neurotic 




Emphysema of the lung in a hoy eight years of age ; diminished cardiac area of relative 

dulness. 

cases of spasmodic asthma. The latter condition is rare in chil- 
dren, and is not accompanied by chronic catarrhal bronchitis. The 
history of these cases is one of repeated attacks of acute bronchitis. 
The lung may in the interval be wholly free from signs of bronchitis. 
A condition of this kind is apt to be left in the lung after a severe 
attack of pertussis. The infants or children may bear the marks 
of rachitis, and are usually anaemic. In the intervals between the 
acute attacks of asthma, the general condition is good. There is no 
fever ; there may be dyspnoea on exertion. An attack of asthma is 
precipitated by exposure to cold or wet. During the attacks infants 



EMPHYSEMA AXD CIIROXIC BRONCHITIS OF THE LUXGS. 369 

and children do not suffer much, although they show signs of 
marked dyspnoea. There are none of the typical signs of an attack 
of spasmodic asthma in the adult. An infant showing very 
marked dyspnoea will play in the arms of the mother. The lips 
may be cya nosed and the surface pale and cool. There is no tem- 
perature. There is in these subjects a tendency to develop a congh 
of a laryngeal type on the least exposure. Examination of the 
chest shows nothing except a prolonged rude respiratory murmur, 
while percussion will give a hyper- resonant note over the whole 
chest. Suddenly an attack of so-called asthma will develop, with 
all the physical signs given below. The onset of the attack is 
sometimes signalized by a slight rise of temperature, 100° to 101° 
F. (37.7° to 38.3° C), and an increase in the number of respira- 
tions, 32 to 36 per minute. On examination, the chest shows all the 
signs of an acute attack of bronchitic asthma. An attack lasts for 
from a few hours to a few days. The children usually play about 
and seem little disturbed by their condition. 

Physical Signs. — During on attack of spasmodic dyspnoea: 

Inspection shows a drawing inward of the supersternal structures 
on inspiration, and a depression of the peripneumonic groove. 
The upper part of the chest is high and filled out, and moves little 
on inspiration and expiration. The lower part of the thorax has 
also little movement. In rachitic children, there is not only drawing 
inward of the lower part of the thorax, but also a distinct incurvation 
of the lower ribs, caused by the repeated attacks of dyspnoea. The 
chest is moved as a whole. In children of ^even or eight years the 
dyspnoea may be severe in the absence of cyanosis. These patients 
apparently suffer more than infants. 

In older children, the chest has the typical barrel shape seen in 
the adult sufferer from asthma (Fig. 07). In one case, my notes 
describe a drawing inward of the intercostal spaces. Some cases 
have a eon-rant cough and frothy expectoration. 

Palpation give- rhonchal fremitus and faint cardiac impulse. 

Percussion gives a vesiculotympanitic or hyper-resonant note over 
the whole chest, and cardiac dulnesa obscured and diminished by 
the emphysematous Lung. 

Auscultation gives a prolonged expiratory murmur and sibilant 
and sonorous rale-. Heart-sounds are feeble. 

Between the attacks of <liisj>n<ra the chest retain- the above forms. 
There may be a slight constant dyspnoea or none at all. The patient 
feels quite well, and does not complain of the dyspnoea. The heart 
apex-impulse is diffused. 

Palpation L r iv<- little or no rhonchal fremitus. Percussion shows 
a note hyper-resonant, but not as markedly so a- during the par- 
oxysm of dyspnoea. Cardiac relative dulnesa is obscured by the 
presence or emphysema. 

24 



370 



DISEASES OF THE RESPIRATORY TRACT. 



Auscultation. — Iu older children the expiratory murmur may 
be prolonged or inaudible. There are signs of residual bronchitis, 
sibilant, sonorous, and subcrepitant rales, and in young infants, large 
mucous rales. The signs may be hardly noticeable or heard only in 
certain portions of the chest. 

Prognosis. — In both forms of chronic bronchitis the prognosis 
quoad vitam is very good. The chances of ultimate restoration of 
the lung to the normal condition depend much on the mode of 
living and the power of the individual to outgrow the conditions of 

Fig. 97. 



■j*f! 






1 . 


1 


1 


— -i 





Emphysema of lung; boy eight years of age ; barrel -shaped thorax. Same patient as Fig. 96. 

rachitis and lymphatism which exist in many of these cases. Many 
of these forms of chronic bronchitis disappear ultimately ; the emphy- 
sematous form may persist into adult life. 

The treatment of chronic bronchitis is directed toward improv- 
ing the general tone of the economy and also the musculature of the 
heart. It must be assumed that in these cases the heart as well as the 
other organs suffers from a lack of power, to which may be attrib- 
uted the relaxed condition of the circulation in the mucous mem- 
brane of the bronchi. Life in the open air, hydriatic treatment, and 
heart tonics, such as strychnine, will have beneficial effects. The 
raucous membranes are benefited by preparations of iron which con- 
tain iodine (syrup of the iodide of iron), freshly prepared and given 



BRONCHIECTASIS. 371 

in large doses. Cod-liver oil is an excellent tonic in winter. The skin 
should be protected from extremes of heat and cold by suitable under- 
wear. Moderate participation in sports in the open air improves the 
action of the heart. Running and gymnastics are to be preferred to 
bicycle-riding. 

A dry climate will do much toward improving the condition of 
the lung. During the attack of dyspnoea, iodide of potassium will 
be of service in alleviating the symptoms. This is the most useful 
remedy. It is also of great benefit when given in the intervals between 
the attacks. The other drugs used with adults are not indicated. 
I have seen good results follow the use of digitalis in the form of 
the tincture, in combination with the iodide of potassium. The heart 
is thus greatly aided in improving the circulatory conditions in the 
emphysematous lung. Rest from exertion is indicated during the 
attack, but patients may be kept out of doors if they will remain 
quiet. Codeine is most useful in allaying the cough. The adminis- 
tration of a large dose once or twice daily, is preferable to giving 
small doses at shorter intervals. 



BRONCHIECTASIS, 

Including Putrid Bronchitis. 

Bronchiectasis, or dilatation of the bronchi, is not a very uncom- 
mon condition in infants and children. In most pulmonary dis- 
orders in these subjects, very slight dilatations of the bronchi may 
result. These have no clinical significance, and retrograde to the 
normal state in time. The marked dilatations are the congenital 
bronchiectasis and the acquired or inflammatory form. 

Congenital Bronchiectasis. — This is a condition of the newly born 
infant which ha- been known to persist into adult life (Grawitz, 
Welch, Kessler, Frankel). It generally affects one lung or a part 
of one lung. The lung structure is replaced by cystic formations 
which contain a serous fluid, in which are found nuclei and ciliated 
epithelium. The main bronchi may be cystic, with a system of 
minor cavities separated from the main cavity by a series of septa. 
In this way numerous recesses are formed. The walls of the cysts 
may be covered with several layers of cuboidal epithelium. No 
distinctive symptomatology has been reported in these cases. 

Morbid Anatomy. — Inflammatory Form. — The inflammatory 
form of bronchiectasis may be sacculated, spindle-shaped, or cylin- 
drical (vicarious). The cylindrical bronchiectasis shows the bronchus 
dilated into a cylindrical form. This dilatation may merge gradually 
or abruptly into the main bronchus. The spindle-shaped bronchiec- 
tasis i- only a form of the cylindrical variety. 



372 DISEASES OF THE RESPIRATORY TRACT. 

The sacculated bronchiectasis is the most common variety, and 
clinically the most important. It usually affects the smaller bronchi. 
A sac communicates with the trachea, and has no other outlet. 
The entry into the sac may be by way of a normal, a dilated, or a 
stenosed bronchus. If the infundibula are dilated, small cavities 
are formed (pulmonary vacuoles). In other cases the afferent 
bronchus may be obliterated, and the cystic formations are then 
of varying size. The wall of the bronchus leading to a cavity of 
this nature is in a state of catarrh, and may be thickened or infil- 
trated. The epithelium may be present only in spots. The infil- 
tration may affect the walls of the alveolar septa. The mucous mem- 
brane may after a time become atrophic. The cartilages of the 
bronchi may also become atrophic and be replaced by connective 
tissue which may extend for varying distances into the lung sub- 
stance, forming trabecular The epithelium of the bronchi may be 
replaced by pavement epithelium. The mucous membrane becomes 
thickened or is replaced by polypoid masses. The bloodvessels finally 
become dilated. There may thus be formed throughout the lung 
small aneurismal dilatations of the bloodvessels. The remaining lung 
tissue may be emphysematous or sclerosed as above. The pleura 
may be thickened. 

Etiology. — Whatever the exact cause of a bronchiectasis, there 
is certainly a diminished resistance of the walls of the bronchus to the 
inroads of inflammatory processes. In order to explain the immediate 
formation of these cavities, Hoffman has assumed that a stenosis of 
the lumen of the bronchus (as shown by Frankel and Lichtheim), 
must be produced by inflammatory processes and that under these 
conditions the repeated attacks of coughing produce dilatation. 
Such stenosis may have its origin in a peribronchitis or a pneu- 
monia causing thickening of the wall of the bronchus. Pleurisy, 
chronic pneumonia, croupous or catarrhal, syphilis, and foreign bodies 
lodged in the lumen of the bronchi may be the direct cause of a 
bronchiectasis. Finally, there are the forms of bronchiectasis called 
primary, because their etiology has not as yet been explained. 

Symptomatology. — The symptoms include expectoration, a 
cough, dyspnoea, deformity of the chest, and fever. 

Expectoration. — There is expectoration of a mucopurulent char- 
acter, which cannot be differentiated from the expectoration of 
some forms of bronchitis. In other cases, large quantities of a fetid, 
purulent material are expectorated. This expectoration may at 
times be mingled with streaks of blood, or there may be a distinct 
hemorrhage. In some cases there is a fatal haemoptysis. Some- 
times the sputum is profuse, exceedingly fetid, fluid, and purulent, 
and will on standing separate into a serous and a purulent portion. 

The cough may be occasional or, if the bronchiectasis exists in 
the apex of the lung, incessant. It is apt to be more marked in the 



BE OXCHIECTA SIS. 



373 



morning, and may at that time be accompanied by the expectoration 
of the sputum accumulated during the night. At other times, change 
of position will cause paroxysms of coughing and the evacuation of 
large quantities of sputum. 

Dyspnoea is present not only during the paroxysms of coughing, 
but also in the intervals, especially if there are extensive secondary 
changes in the lungs or pleura. 

Fever of a hectic character is very likely to be present at times 
when the secretion in the lung accumulates. The temperature will 
then show a rise of a degree or more, but subsides when the lung is 
again cleared of bronchiectatic accumulations (Fig. 98). The rises 

Fig. 98. 



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Bronchiectasis : febrile and afebrile periods. Boy, seven years of age. 

of temperature may simulate those in empyema or tuberculosis. If 
abscess of the liver or kidney, endocarditis, or pneumonia occurs as 
a complication, the rise of temperature will be more marked. 

Deformity of the chest is apt to occur in severe cases in which 
there is emphysema of the lung or pleuritis. In 3 of my cases 
there have been deformities of the fingers and toes. These, the 
so-called clubbed fingers, are not characteristic of bronchiectasis, 
since they are found in congenital cardiac disease and tuberculosis 
of the lung. 

Complications include decomposition of the bronchiectatic accu- 
mulation-, pneumonia, gangrene of the lung, emphysema, pleurisy, 
empyema, perforation of the lung, laryngeal disease, kidney and 
heart disease, liver abscess, abscess of the brain, and finally amyloid 
degeneration of the liver, spleen, and kidneys. 

Diagnosis. — A positive diagnosis of bronchiectasis cannot always 
be made, especially in those cases in which there are all the signs of 



374 



DISEASES OF THE RESPIRATORY TRACT. 



a localized empyema. Such cases show localized dulness or flatness, 
bronchophony, and absence of fremitus in a certain portion of the 
chest, generally at the lower portion behind. A needle, on being 
introduced, withdraws pus, which in the cases I have seen was min- 
gled with air bubbles. On operation, the pleura is found to be 
normal. In 3 instances I found this to be true. The evidence 
of a bronchiectatic cavity lay in the persistence of signs and symp- 
toms after the healing of the chest wounds. In all 3 cases the 
expectoration persisted in profuse quantities after operation (Fig. 99). 

Fig. 99. 




Showing bronchiectatic cavity in case of a girl eight years of page, with signs as noted in 

text. 

The physical signs in all of my cases included a localized area 
of dulness or flatness, over which there was bronchophony and bron- 
chial breathing, in some cases with gurgles. Above this area, over 
the base behind, there was on percussion a tympanitic note, indi- 
cating the enlarged bronchus containing air. Tuberculosis is 
excluded by the absence of tubercle bacilli in the sputum, but bron- 
chiectasis and tuberculosis may coexist. In most of my cases there 
was a history of an antecedent attack of pneumonia. Exclusion of 
abscess of the lung is very difficult in severe cases in which the 
quantity of sputum is excessive. The bronchiectatic cavity in these 
cases is very large. With the bronchiectasis, there may be diffuse 
bronchitis and emphysema of the lung. 



LOBAR PNEUMONIA. 375 

Course. — Some of the eases in which the bronchiectasis is not 
marked or progressive result in spontaneous recovery. In others 
there may be tuberculosis, gangrene of the lung, or empyema, as 
complications. A fatal haemoptysis may close the scene of this very 
offensive affection. 

Treatment does not give very satisfactory results. It includes 
the inhalation of balsams of all kinds, out-of-door life in high alti- 
tudes, and surgical interference including exposure of the lung and 
incision of the bronchiectatic cavity. The latter is a desperate 
remedy ; in some cases it has resulted in fatal hemorrhage and in 
others has not afforded relief. A cure has resulted in a few rare 
cases in which there was a simple cavity in the lung near the 
pleural surface. The injection of these cavities with drugs has also 
been very unsatisfactory. 



LOBAR PNEUMONIA. 

Lobar pneumonia or fibrinous pneumonia is an acute infectious 
disease, caused in the majority of cases by the Diplococcus pneu- 
monia? (Frankel ). A few cases are caused by the Bacillus pneu- 
moniae (Friedlander) ; others, by the Streptococcus or Staphylococcus 
pyogenes. 

Occurrence. — Lobar pneumonia occurs as a primary disease 
or may complicate typhus fever, typhoid fever, influenza, rheuma- 
tism, malarial fever, erysipelas, osteomyelitis, meningitis, and neph- 
ritis. According to Keller, from 58 to 62 per cent, of all lobar 
pneumonias occur among children, the frequency among boys being 
greater (55.9 per cent.). Fully two-thirds of the eases occur during 
the winter and early spring. Pneumonia of any variety, and espe- 
cially of this form, may occur in groups of persons or in small local 
epidemics. Without doubt, certain houses and rooms harbor the 
pneumonia poison for some time, as is evinced by the repeated 
occurrence of cases in certain places (Jurgensen). Cold favor- the 
development of pneumonia by reducing the resistance of the economy 
to the invasion of bacteria, but it cannot be regarded as a cause of 
the diseas 

Age. — Lobar pneumonia may occur at any age of infancy or 
childhood. Von Jaksch has shown that it occurs among young 
infants. My own experience confirms this statement. Out of 839 
of my cases of pneumonia of all types, 582, or i>!> per cent., occurred 
before the end of the second year; the greatest frequency was 
between the first and second years (282 cases). From birth to the 
sixth month the frequency is less than from the sixth month to the 
end of the second year. 

Sex. — The male Bex -how- the greater number of cases (436 



376 DISEASES OF THE RESPIRATORY TRACT. 

males, 403 females). Of 147 cases of carefully observed lobar 
pneumonia, 89 were males and 58 females. 

Seat of the Disease. — Jiirgensen shows that in 162 cases, both 
lungs were affected in 7.4 per cent. The right lung only was 
affected in 43.2 per cent, of the cases. When the right lung was 
attacked, the lower lobe was generally the seat of the disease (25.3 
per cent.). The lower lobe of the left lung was consolidated in 35 
per cent, of the cases. 

Of 147 of my cases of lobar pneumonia, the right lung was 
involved in 79 cases and the left in 68 ; the upper right lobe was 
involved in 50 cases ; the upper left, in 28. The upper lobe of 
either lung was involved in 78 cases, as against 61 cases of the lower 
lobes. The middle right lobe was involved in only 8 cases. 

Upper lobe. Middle lobe. Lower lobe. 

Eight lung 50 8 21 

Left " 28 40 

Pneumonia of the upper lobe is more frequent in children than 
in adults. According to Jiirgensen, the greater frequency of pneu- 
monia in the right lung may be attributed to the larger size of the 
right bronchus and the more direct communication with the lung. 

Morbid Anatomy. — Lobar pneumonia in infancy and child- 
hood is, as in adult life, distinguished by the occurrence of a 
fibrinous exudate in the alveoli of the lungs, bronchioles, and lymph- 
spaces. This exudate is composed of desquamated epithelium, leu- 
cocytes, red-blood cells, and fibrin. The proportion of leucocytes, 
red blood-cells, and fibrin varies greatly at different stages of the 
affection. A fluid exudate may be present if the quantity of fibrin 
is small. In such cases there is a lobar catarrhal process or an 
inflammatory (edema of the lung. The exudate begins with con- 
gestive hyperemia. The lung is dark red and of increased con- 
sistency. With the appearance of coagulation there is produced a 
condition of hepatization in which the lung is solid, and has the 
appearance of liver. The bloodvessels are filled with red cells. If 
the vessels are less engorged, the lung has a grayish tint. This 
later stage, called gray hepatization, is the condition most frequently 
seen at autopsy. The hepatized lung does not contain any air, and 
on section shows a granular surface, the granules being the so-called 
pneumonic granules of the later stage of the disease. The pleura 
is as a rule inflamed. It is without lustre and may be thickened 
and covered with fibrin. There may be considerable serous or sero- 
purulent exudate in the pleural cavity. The extent of hepatization 
varies. It may involve a whole lobe, part of the lobe of a lung, or 
parts of both lungs. On inspection of the surface of a section, 
small yellow areas may be seen in the hepatized portions. These 
are areas poor in fibrin, and correspond to the situation of the 
bronchioles of the lung. 



LOBAR PNEUMONIA. 377 

The bronchial nodes may be red and swollen, the bronchi being 
the seat of inflammation. The bronchioles may be filled with fibrin 
and red blood-cells. 

Resolution occurs on from the seventh to the tenth day of the 
disease. At this time liquefaction of the inflammatory products 
which are eliminated by expectoration occurs. Complete restoration 
of the lung to the normal may occur between the second and the 
fourth week, at which time the periphery of the alveoli may be found 
to be rich in cells. There may still exist catarrhal processes which 
have succeeded the fibrinous changes. The pleura may remain 
thickened and be the seat of adhesions. 

An unfavorable or malignant ending, such as gangrene or sup- 
puration, is rare, and is as a rule due to some mixed infection favored 
by an old bronchiectasis or putrid bronchitis. Unless a tuberculous 
infection occurs, caseation in lobar pneumonia is unknown. Indu- 
ration of the lung, cirrhosis or carnification, is a peculiar condition 
which may occur from the fourth to the tenth week. The lung 
assumes a beefy red appearance and is tough, hypersemic, and 
infiltrated with small round cells. The alveoli enclose a large 
number of connective-tissue cells. There is a proliferation of newly 
formed bloodvessels in the septa of the luug. The bronchial, peri- 
bronchial, and pleural tissues are proliferated. Induration of the 
lung by pleural adhesions results. The alveoli of the lung may 
be replaced by connective tissue and epithelium. Induration may 
take the form of bands of connective tissue, which may extend from 
the pleura into the lung, enclosing areas of lung-tissue. 

Bacteriology and Etiology. — The pneumococcus of Frankel is 
now recognized as the etiological factor in lobar pneumonia. As 
has been mentioned, the Bacillus pneumoniae of Friedlander is 
found in a small number of cases, with the pneumococcus or 
with other bacteria. The Streptococci pyogenes and the Staphy- 
lococcus pyogenes arc sometimes found, as well as the Bacillus 
typhosus. In the cases of secondary infection, the Diplococcus pneu- 
moniae or the Staphylococcus pyogenes is found. In the majority 
of fatal cases, Kohn found the pneumococcus circulating in the 
blood. The cases which show the diplococcus in the blood and 
which recover, do so with complications. In a recurrent pneu- 
monia of infancy, Pcrutz found an osteomyelitis of the joint, caused 
by pneumococci. In one of my cases which was followed by bilateral 
empyema, there was a peri-articular abscess containing pneumococci. 
According t<> Landouzy and Xetter, the pneumococcus is capable 
of producing suppuration without the intervention of streptococci 
or staphylococci. Cases of severe icterus are due to the hsemolytic 
action of the pneumococci on the blood. Gaillard has shown that 
the enteritis in pneumonia i- caused by pneumococci. 

Symptomatology. — There are form- of fibrinous or lobar 



378 DISEASES OF THE RESPIRATORY TRACT. 

pneumonia which present the same symptomatology in children as 
in the adult. On the other hand, certain sets of symptoms referable 
to the nervous system and intestinal tract, as well as the character 
of the variations in temperature, are peculiar to infancy and 
childhood. 

The disease may be ushered in by a chill, which may be severe 
or only amount to a sensation of chilliness. Susceptible subjects 
may, with the rise of temperature, be attacked with convulsions. 
Other patients pass into a stage of delirium lasting for days. 
Cases of pneumonia ushered in with cerebral symptoms are apt to 
mislead the physician, especially if meningitis has been recently 
prevalent. There are also cases, especially in children, in which 
there has been a preceding bronchitis. These should not be regarded 
as being of necessity cases of bronchopneumonia. Sometimes the chill 
is coincident with a sharp attack of enteritis. The character of the 
invasion will thus vary with the severity of the infection and the 
susceptibility of the subject. After the initial chill, there is in the 
simple cases a sharp rise of temperature. The height of the fever 
varies, and in young infants is apt to mount to 106° F. (41.1° C). 
There are cough and considerable dyspnoea, varying with the extent 
of lung involvement. In infants and children the dyspnoea is quite 
apparent to the eye of the observer, and will prompt him to surmise 
that the lung may be involved. Older children have a distressed 
expression. 

The patient complains of pain, which is in many cases referred 
to the side affected. In younger children the pain is quite fre- 
quently referred to the epigastrium, but sometimes to the region of 
the abdomen low down, or to the right side of the abdomen low 
down over the situation of the vermiform appendix. Pain is apt 
to be referred to this region in cases of lobar consolidation of the 
lower portion of the right lung. These are often, in the early 
stages, diagnosed as cases of appendicitis. The face is pale or 
quite flushed. The dyspnoea may be slight, but is quite marked 
in some severe cases. Even if both lungs are involved, it may 
not be intense. There is a cough. In older children there is 
expectoration of rusty sputa. Infants and young children swal- 
low the sputum. Infants cry with each paroxysm of coughing ; 
older children complain of pain. Sometimes infants and children 
vomit with each attack of coughing. After the fever has persisted 
with these symptoms for from five to nine days, there occurs in 
the vast majority of cases a fall of the temperature — the so-called 
crisis — which may take place within from three to six hours, or 
may extend over thirty-six hours. The fall of temperature may 
be followed by a temporary rise of a few degrees (Fig. 100) — the 
so-called pseudocrisis ; within a few hours it then falls to the 
subnormal, where it remains for a few days after the crisis, finally 



LOBAR PNEUMONIA. 



379 



rising to the normal and remaining at that point throughout con- 
valescence. The temperature may fall by lysis, that is to say, by 
reaching with gradual remissions the normal, or as a rule the sub- 
normal, within from forty-eight to seventy-two hours. 

Consideration of Individual Symptoms. — The Temperature. — 
The temperature-curve in lobar or fibrinous pneumonia may be of 
several distinct types. In the majority of cases the temperature 
remains persistently high for the whole period of the illness. There 
are morning remissions of a degree or more, but the afternoon or 

Fig. 100. 



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evening rise may reach 104°, 105°, 106° F. (40°, 40.5°, 41.1° C.). 
In a typical case the morning remissions are not so great as those in 
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the subnormal within thirty-six hours. 



380 



DISEASES OF THE RESPIRATORY TRACT. 



Another very distinct form of temperature-curve is the remittent. 
This temperature-curve is at first glance exactly similar to that of 
bronchopneumonia. The remissions in the morning may reach the 
normal within a fraction of a degree. Such cases may also show at 
the terminal end of the curve a critical drop to the normal. In 
other cases the fall of temperature at the beginning of convalescence 
takes place by what is known as lysis (Fig. 102). In other words, 
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temperature in a gradually descending scale extending over two or 
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begins at the ninth day of the disease, and is not completed until the 
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indicated. Female child, two years and five months of age. 



apparently no complications. The more common type is that in 
which the lysis begins on the seventh or eighth day, and is completed 
in two or three days. Of 57 cases of lobar pneumonia in which a 
reliable history could be obtained, the temperature fell by crisis in 36 
and by lysis in 21 cases. The crisis, as a rule, occurs from the fifth 
to the ninth day of the disease (60 per cent, of my cases). After 
the lysis or crisis there may be a slight daily rise in temperature of 
a degree or even less, probably indicative of a very mild form of 
post-pneumonic pleurisy. The temperature in such cases falls grad- 
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The subnormal temperature after the crisis or lysis is quite a 
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ately severe course, is accompanied by irregularity or abnormal 



LOBAR PXEUMOXIA. 



381 



slowness of pulse. A slow pulse (bradycardia) which is at the 
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382 



DISEASES OF THE BESPIBATOBY TRACT. 



should be regarded as a reaction from the toxaemia which has affected 
the heart muscles. 

At the crisis in lobar pneumonia I have, in exceptional cases, seen the 
temperature drop within an hour from 103° to 94° F. (34.4° to 39.9° C) and 
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subnormal temperature intermittent in character; recovery. Female child, two years and 
six months of age. 

accompanies the cough, and may be suspected if the infant or child 
cries when it coughs. The pain is referred to the side of the chest, 
to the epigastrium, or to the region of the appendix. The pain 
referred to the appendix in cases of lobar pneumonia is probably 
radiated from a diaphragmatic pleurisy. 

Dyspnoea. — Infants and young children show marked dyspnoea. 
The alee nasi are dilated and the peripneumonic groove is depressed 
with each inspiration. In very severe dyspnoea in young infants, 
there may be a drawing inward at the suprasternal notch. This 
occurs even in the absence of any laryngeal disturbance, and fre- 
quently simulates laryngeal stenosis. 

Nervous Symptoms. — The cerebral symptoms may at the out- 
set simulate those of cerebrospinal meningitis. There are delirium, 
rigidity of the muscles of the neck, and even opisthotonos. There 
may be no true meningitis. Older children may have a low, mut- 



LOBAR PNEUMONIA. 383 

tering delirium during the whole course of the disease. Near the 
crisis aud just before the fall of temperature, I have in a few cases 
seen maniacal delirium, in which the patients were very noisy and 
attempted to get out of bed. I have seen cases of melancholia with 
crying spells during convalescence in female children, and also in 
boys. These symptoms all subsided in time and the patients were 
eventually fully restored. 

The Blood. — It has been noted by Tumas and von Jakseh 
that in pneumonia of the fibrinous variety there are a marked leuco- 
cytosis and an increase in the niultinuclear leucocytes, which is 
especially marked at or near the crisis. The proportion of leuco- 
cvtes to the red blood-cells in the cubic millimetre may reach 
1 : 40 to 1 : 70. Ehrlich believes this leucocytosis to be a very 
constant occurrence in typical pneumonia. Billings has investigated 
the relationship of the leucocytosis to the prognosis more fully. 
His work will be referred to in the consideration of the prognosis. 
My own experience covers about ninety cases of fibrinous and bron- 
chopneumonia, examined with reference to leucocytosis. Leucocytosis 
i- present in both forms of pneumonia in infancy and childhood, but 
is more marked in the fibrinous forms, the number of leucocytes to the 
cubic millimetre being about twice as great as in the catarrhal forms. 
There was marked leucocytosis in the fatal cases of both forms of 
pneumonia. The increase of the leucocytes in the fibrinous forms 
was especially marked at the time of the crisis. In the broncho- 
pneumonic forms the leucocytes were also high at or about the 
time of the drop in temperature. The diminution of the number of 
leucocytes was in both forms marked either just previous to or after 
the fall in the temperature. From the observations of Billings 
and Ewing, it must be concluded that leucocytosis is a favorable 
sign in fibrinous pneumonia. It does not, however, as Ewing 
believed, bear any exact ratio to the extent of lung involved. I 
have found a much higher percentage of leucocytes to the cubic 
millimetre in children than Ewing found in the adult. Thi< i- 
probably due to the fact that any leucocytosis is more marked in 
infants and children than in the adult subject. The absence of 
leucocytosis is certainly a grave prognostic sign, but the presence 
of marked leucocytosis in children does not in my experience 
preclude a fatal issue. 

Physical Signs. — The signs obtained by physical examination 
of the chest in fibrinous pneumonia of infante and children resemble 
those of the same condition in the adult. In tonus of broncho- 
pneumonia or catarrhal pneumonia in which areas of considerable 
extent are consolidated the signs will closely resemble those obtained 
in the fibrinous form. The physical signs of lobar or fibrinous 
pneumonia are classified a- those of the first, second, and third stages 
of the disease. 



384 DISEASES OF THE RESPIRATORY TRACT. 

First Stage, Stage of Engorgement of the Lung. — On inspection 
the signs of dyspnoea above noted are found. 

Palpation at this stage will in an uncomplicated case give no 
signs, even over the affected area. If bronchitis complicates the 
case, rhonchal fremitus may be obtained. At this stage the differ- 
ence in fremitus between the affected and the unaffected side of the 
chest is not perceptible. 

Auscultation. — In the first stage of the disease auscultation 
may discover a rude respiratory murmur on the healthy and diseased 
sides which is more marked in the latter and on inspiration. The 
pathognomonic sign at this stage is the crepitant rale, which is 
sometimes easily found and is at others very elusive. It may be 
present before an attack of coughing, and disappear after the bronchi 
have been cleared, and is, as a rule, heard over a very limited area. 
It is therefore necessary to examine the chest very carefully in front, 
behind, and in the axillary line for this sign, before deciding posi- 
tively as to its presence or absence. It may be present for a few 
hours only. 

Percussion will at this period give slight dulness over the 
affected area of lung. The dulness may be slightly tympanitic. 
This is caused by the fact that at the outset of consolidation there 
is still some air in the affected area. Under these conditions there 
may be what is known as tympanitic dulness. This condition is 
especially found in young infants, in whom the chest-wall is thin, 
and in whom sounds are very well obtained by gentle percussion. 

The Second Stage, Stage of Consolidation. — If the lower portion 
of the right lung is affected, we shall get by palpation in front over 
the upper part of the chest nothing abnormal ; over the lower part 
of the chest in front there will be an increase of the vocal fremitus, 
which is also apparent behind. Percussion over the upper part of 
the right lung will give a vesiculotympanitic note in front and 
behind. The unaffected side will give normal pulmonary resonance. 
In exceptional cases the percussion-note over the upper lobe of the 
lung in front may give the so-called cracked-pot sound. In front, 
behind, and in the axillary line over the lower lobe which is affected 
there is dulness — not at first complete. When consolidation is com- 
plete, the dulness is quite marked. In cases in which some pleuritic 
effusion exists over the consolidated area behind, the percussion-note 
may be quite flat. In cases in which the upper lobe is consolidated 
there will be signs of consolidation, while lower down the note is 
exaggerated or vesiculotympanitic over the unaffected mid-region of 
the lung, and over the base there will also be marked dulness. This 
lower area of dulness should not be regarded as a sign of consoli- 
dation. It is really due to the accumulation of a small amount of 
serous effusion in the lower part of the pleural cavity as a result of 
the complicating pleurisy. 



LOBAR PNEUMONIA. 385 

Auscultation will in this stage give bronchial voice and breath- 
ing over the affected area of the lung; over the unaffected lung the 
respiratory murmur, especially the inspiratory sound, is harsh. This 
harsh inspiratory sound is quite common in children, and is fre- 
quently mistaken for bronchial breathing. Bronchial breathing is 
tubular in quality on inspiration and expiration. In this stage, if 
the upper lobe of the lung is also involved and there is some pleuritic 
effusion in the chest, the respiratory murmur may be much weakened 
over the lower region of the chest behind. 

The voice also has a tubular or bronchial quality over the con- 
solidated area. The intensity of the voice may be diminished over 
the lower portion of the chest if pleuritic effusion is present with 
consolidation of the upper lobe. Pleuritic rales may in this stage 
be heard over the whole side of the chest. 

Third Stage. — The third stage, that of resolution, is sometimes 
delayed, some days elapsing after the crisis before appearance of the 
sign pathognomonic of this stage — the so-called rale redux. This 
rale has the same qualities as that heard in adults at the same stage. 
In children it is sometimes present for only a short time, and is not 
heard over any considerable area of the lung. I have known the 
temperature to be subnormal for two days or more before its appear- 
ance. The other sign, which is less important, is a distinct diminu- 
tion of the fremitus until it reaches the normal intensity over the 
affected area of lung. The percussion-note becomes less dull, 
assuming the vesiculotympanitic quality. Repeated auscultation 
reveals, in addition to the rale redux, a gradual return of the voice 
and breathing to the normal, which sometimes takes weeks. The 
tubular quality of the voice and breathing over the affected area 
of lung may persist long into convalescence. It is probably not 
caused by any actual persistence of consolidation, but by a con- 
tinued hyperemia of the lung. The lung under these conditions is 
denser and conducts sounds from the bronchi with greater intensity 
than the healthy lung. If pleurisy has been present to any extent, 
there may, after the disappearance of the signs of consolidation, be 
signs of dry pleurisy or those of effusion. 

Pneumonia of an Unusually Short Course. — Leube and Weil have 
recorded in the adult typical pneumonia of the fibrinous variety 
and of very short duration. Some of these cases exhibit the chill, 
fever, pain, and crisis, with other signs of physical involvement 
of the lung, within twenty-four to thirty-six hours. Jurgensen has 
recorded short lethal pneumonias of the fibrinous variety in the 
adult. The ease- of Levy and Jurgensen were i'atal within twenty- 
four to thirty-six hours. I have never met such eases of fibrinous 
pneumonia in children. In eases running such a course there is 
doubt a- to whether the signs obtained over the chest may not have 
been connected with a preceding attack. Henoch has, however, 



386 DISEASES OF THE RESPIRATORY TRACT. 

met a few cases which ran a rapidly fatal course with the whole 
symptomatology of lobar pneumonia including physical signs, in 
forty-eight hours. 

Complications. — Among the complications of fibrinous pneumo- 
nia in infants and children are otitis, pleurisy, pericarditis, endocar- 
ditis, empyema, and meningitis. Some writers record peritonitis ; 
I have not met a case. Gastro-enteritis is quite a common compli- 
cation. 

Otitis is common, its frequency varies in different epidemics. 
It affects younger children and infants more frequently than older 
subjects. The temperature in these cases becomes more markedly 
remittent and remains higher for a greater length of time than in the 
uncomplicated cases. I have frequently suspected otitis from a study 
of the temperature-curve, which is not, however, an altogether 
reliable guide. Suppuration in the pleura will give a similar curve. 
Therefore, in a concrete case of persistent high temperature-curve 
with morning remissions, otitis should be suspected, but not posi- 
tively diagnosed without careful exclusion of other complications. 
Otitis as such does not seem to give any striking symptoms of pain. 
The patient may without warning present perforation of the drum 
of one or both ears and a purulent discharge. The temperature 
will then fall to the normal. Diplococcus pneumoniae has been found 
by a number of observers in this discharge. The otitis is of a benign 
nature. 

Meningitis occurs in a number of cases, and may usher in the 
disease. I have seen it persist for weeks. The prognosis in this 
form of meningitis, if it assumes the cerebrospinal type, is graver 
than when it occurs as a primary disease, with the intracellular dip- 
lococcus of Weichselbaum as a causative factor. Netter seems to 
have met a larger number of cases of the pneumococcus form of 
meningitis than any other author. The cases of meningitis compli- 
cating pneumonia should not be confused with those presenting cere- 
brospinal symptoms. The cerebrospinal symptoms seen at the outset 
or at the crisis in some cases of pneumonia do not last for any great 
length of time, and do not present the true symptoms of meningitis. 

Pleurisy and Empyema. — Many cases of fibrinous pneumonia show 
a dry pleurisy sometimes persisting for a long time after convales- 
cence. Of greater moment are the cases of pleurisy with effusion, 
which follow a lobar pneumonia. In these, there is always the danger 
that the exudate may eventuate in an empyema. The duration of 
the exudate is no guide in determining whether it is of a serous or a 
purulent nature. It is frequently found that after a pneumonia has 
run its course the temperature remains raised a degree or more 
toward evening. Such a rise in temperature may, in the absence of 
siVns of fluid, indicate a dry plastic pleurisy (Fig. 105). On the 
other hand, if there are signs of fluid and the temperature-curve 



LOBAR PNEUMONIA. 



387 



shows irregularities of rise, empyema may be present. I have met 
empyema without any rise of temperature in infants who showed 
the physical signs of fluid in the chest. These points will be more 
fully discussed under the head of Empyema. 

Pericarditis. — I have seen periearditis in infants who died of 
a fibrinous pneumonia, but the diagnosis was not made during 
life. Von Jaksch notes such eases. In older children, pericarditis 
is a complication found in eases of fibrinous pneumonia which 
have simultaneously developed empyema. Such cases are very 
uncommon. In the form of periearditis which I have seen in 
infants, the quantity of effusion has not been sufficiently great 
to enable a diagnosis to be made with certainty, and the rales 
in the lung obscured the friction-sounds in the pericardium if they 
were present. Purulent pericarditis in these subjects is very fatal 

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Lobar pneumonia, lower lobe, left lung; complicating pleurisy; temperature falling grad- 
ually to the normal. Leucocyte count indicated. Boy, five years of age. 



under such conditions. In older children I have seen pneumonia 
combined with a fibrinous pericarditis pure and simple, without fatal 
issue. 

The prognosis of lobar pneumonia varies within certain limits. 
Text-books give statistics taken from hospital cases, notably the 
most unfavorable material. Henoch gives the mortality of his cases 
at 5 per cent. ; Baginsky, at 8 per cent. ; Holt, at 1 '2 per cent. ; my 
own hospital cases during the past year showed a mortality of 8 per 
cent. On the other hand, in private practice death from an acute 
fibrinous pneumonia rarely occurs in a child previously healthy and 
living in good surroundings. The mortality is influenced by the 

on of the year, being greater from December to February, and 
by the presence of an epidemic. If pneumonia is prevalent during 
an epidemic of influenza, the mortality will increase. Pericarditis or 



388 DISEASES OF THE RESPIRATORY TRACT. 

complicating empyema influence the death-rate. The previous con- 
dition of the patient, the mode of feeding (whether by the breast 
or the bottle), and a rachitic or marantic condition, affect the prog- 
nosis. The age of the patient is also an important factor. Infants 
under one year of age are in greater danger than older ones. The 
prognosis is best from the third to the tenth year. The younger 
the bottle-fed baby, the more serious the complication of empyema. 
In making a prognosis in any concrete case, the physician should be 
guided by the extent of lung involvement and the general condition 
of the circulation. If one lobe alone is involved and there is an 
absence of bronchitis in the unaffected lung, the outlook is good. 
If the heart action is good and there is an absence of cyanosis, 
recovery can be predicted even if the temperature be high. If, on 
the other hand, the lysis or crisis is delayed and the dulness or flat- 
ness involves a whole side of the chest, in the presence of signs of 
a weak heart the prognosis should be made with caution. Menin- 
gitis of pronounced type is grave. Pericarditis in young infants 
and children is a complication invariably fatal. 

The diagnosis of lobar pneumonia in infancy and childhood 
ordinarily presents few difficulties, but is not easily made if in addi- 
tion to the pneumonia there is an effusion in the chest. The diag- 
nosis should never be made early in the disease without positive 
signs. 

The crepitant rales sometimes escape observation. The physician 
should then wait for the appearance of dulness or bronchial voice 
and breathing before arriving at a conclusion as to the presence or 
absence of consolidation. Cases of influenza with a harassing cough 
are frequently diagnosed as central pneumonia. A pneumonia which 
is central will give physical signs. If after the time set for the 
crisis or lysis, the temperature persists and becomes remittent, careful 
examination should be made for evidences of fluid in the chest. The 
nature of the fluid should be determined by exploration with the 
aspirating needle, if the fever does not subside and if the dyspnoea 
increases. A chest effusion in infants and children is apt to be 
purulent. 

The cerebral cases present difficulties of diagnosis. Convulsions, 
delirium and rigidity of the neck, accompanied by high fever and a 
cough, with increase of the pulse-rate and the number of respirations, 
indicate the necessity of making a very careful examination of the 
chest. 

In cases which begin with a lobar pneumonia, typhoid fever may 
be suspected if, after the first days of illness, a roseola or an enlarge- 
ment of the spleen develops with a continuance or gradual rise of 
temperature. In such cases the presence of an epidemic of typhoid 
fever and the Widal blood reaction will be of service in clearing up 
the diagnosis. 



LOBAR PNEUMONIA. 389 

The treatment of lobar pneumonia is pre-eminently expectant. 
The disease is self limited, and complications cannot be prevented. 
The temperature should be treated within certain limits, and the 
heart and the strength of the patient supported. The temperature 
should be treated not with a view to its actual reduction, but in 
order to mitigate its ill effects. Infants and children will be less 
affected by a temperature of 103° F. (39.4° C.) lasting during the 
time while a pneumonia runs its course than by the same tempera- 
ture in typhoid fever. The toxaemia of pneumonia is of a more 
benign character. Cold applications are relied on to reduce the 
temperature. 

Hydrotherapy. — Sponging is efficient in eases in which the tem- 
perature does not generally range above 104° or 104.5° F. (40° C). 
The younger the infant the less energetic need it be, for a tempera- 
ture of 104.5° F. (40° C. ) is not high for an infant under two years 
of age. I content myself with sponging of the body with water at 
80° F. (26.6° C), to which some alcohol has been added. If the 
temperature remits a degree or more during the twenty-four hours, 
there will be less need of sponging. The temperature should 
never be taken more often than every three hours. If it is above 
103.5° F. (39.7° C), the patient is sponged for fifteen minutes and 
then given absolute rest for three hours. Frequent sponging is 
pernicious. Some infants when sponged with water at 80° F. 
(26.6° C.) become blue, the pulse becoming rapid and thready. With 
these subjects a warm bath at a temperature of 105° to 107° F. 
(40.5° to 41.6° C.) is stimulating. It supports the strength and cer- 
tainly lessens the ill effects of the temperature, although it may not 
reduce it palpably. I do not use the full cold bath in the treatment 
of lobar pneumonia in infants and children. If the temperature 
reaches 105°-106° F. (40.5°-41.1° C), a full bath of the tempera- 
ture of 85°_90° F. (29.4°-32.2° C.) or higher may be given, cer- 
tainly never lower. 

One of the most useful methods of hydrotherapy in the treatment 
of pneumonia in young infants is the so-called chest compress 
(page 35). These compresses renewed every hour will cause the 
restlessness to diminish, the heart action to improve, and the patient 
to fall into a quiet slumber. The actual reduction of temperature 
is not BO marked as the favorable effect on the general condition of 
the patient. The application of compresses is discontinued if the 
temperature falls below 103° F. (39.4° C). 

Medicinal Treatment. — The heart action if good needs no atten- 
tion. At most, a limited amount of wine or whiskey is administered. 
Infants may receive half a drachm (2.0) every few hours ; older 
children, a drachm (4.0). Whiskey should not be given as a routine 
remedy. It' tin- temperature La high necessitating hydrotherapy, 
and the pulse is above 120, whiskey should be given. W the pulse 



390 DISEASES OF THE RESPIRATORY TRACT. 

is high, 150-1 GO, a few minims of the tincture of digitalis may be 
given to older children. Younger children rarely need more than 
half a minim every two to three hours. If the pulse-rate is reduced 
after the administration of digitalis, the drug should be discontinued 
before the pulse drops below 100. There is no doubt that its effect 
is more cumulative in some subjects than in others. 

Strychnine is of value in the treatment of pneumonia, not so 
much in the cases with rapid as in those with slow and irregular 
pulse. Infants will bear grain -jj^ to yj-^ (0.0003 to 0.0004) every 
three hours, for days. 

Caffeine is of great value in the treatment of irregularities of the 
heart which indicate a myocarditic process. The pain is the result 
of a pleuritic process. 

The local application of iodine or mustard paper is an efficient 
counter-irritant. If the cough is troublesome, codeine in moderate 
dosage is the most useful remedy. 

I never make use of morphine with infants and children. In 
young infants the milder preparations of opium, such as camphorated 
tincture or the wine, are most useful. Four minims (0.25) of the 
camphorated tincture of opium every two or three hours will be 
found efficient in children under two years of age. To older children 
a small dose of codeia may be given several times daily if needed. 
The aim is to alleviate the pain and cough. 

The bowels should be evacuated daily ; for this purpose hydrarg. 
cum creta is one of the best remedies. Grain v (0.3) may be given. 
Infants should receive an enema daily. 

If gastro-enteric disturbances are present, the giving of milk 
should be discontinued and the same procedure followed as in 
primary gastro-enteritis. 

Tympanites is sometimes troublesome, especially in young chil- 
dren. The best remedy is a high enema twice daily of salt solution, 
to which one or two teaspoonfuls of peppermint- water have been 
added. The passage of a soft catheter is not effective, nor are the 
turpentine stupes of any value. 

The delirium, sometimes amounting to an acute mania, which 
appears just before the crisis in some cases, is best controlled by 
rectal administration of bromide of potassium and chloral hydrate. 
I have sometimes been forced to keep the patient under the influence 
of these drugs for a few days. The post-pneumonic melancholia 
seen in children is best treated by the administration of strychnine 
and the enforcement of perfect quiet. 

Should signs of extreme cardiac weakness set in with threatening 
oedema of the lung and paralysis of the right ventricle, nitroglycerin 
is of great value. Infants will bear grain -^-^ (0.0003) every three 
hours. If in these cases cyanosis is present, oxygen is administered, 
preferably that containing 20 per cent, of nitrous oxide. It is given 



BRONCHOPNEUMONIA. 391 

to infants, every half hour for five or ten minutes at a time by 
means of a cone. 

Hygiene. — The patient should be isolated if possible. The room 
should be ventilated and its temperature kept at 68°-72° F. (20°- 
22.2° C). 

The sputum should he received in pieces of gauze, which are 
burned. The mouth and teeth should he cleansed twice daily with 
a piece of soft linen and a solution of boric acid. In the intervals 
between feedings the tongue is kept moist by frequent draughts of 
water. 

BRONCHOPNEUMONIA. 

Bronchopneumonia is the prevalent type of pneumonia occurring 
before the fifth year, but there are also many cases of lobar fibrinous 
pneumonia during the periods of infancy and early childhood. 

Bronchopneumonia occurs both as a primary and a secondary 
disease. As a primary disease it is most frequent during the first 
two years of life. Of 605 of my cases of bronchopneumonia, the 
incidence in regard to age was as follows : 

Cases. 

One to three months 32 

Three 10 six months 68 

Six to twelve months 207 

One to two years 298 

These figures correspond within certain limits to those of other 
authors, although Holt places the greatest frequency between the 
sixth and the twelfth months. 

Sex. — Of the 605 cases, 322 were males — a statement corre- 
sponding to that of Jurgensen in regard to lobar pneumonia. 

Season. — The greatest frequency is during the winter months, 
when there are epidemics of influenza during which many primary 
and secondary cases of bronchopneumonia occur. 

Surroundings. — The herding together of the poor certainly has 
a tendency to increase the prevalence of bronchopneumonia among 
them. If we believe in the epidemiological aspects of pneumonia, it 
i- easy to account for the greater frequency of the disease among the 
poor: the greater number of their children are rachitic, syphilitic, 
marantic and ill-fed, and thus have increased susceptibility to in- 
fection. 

Secondary bronchopneumonia occurs as a complication in the 
exanthemata (measles, scarlet fever, typhoid fever), diphtheria, per- 
tussis, and influenza. By far the greater number of cases occur as 
a sequence of ordinary bronchitis. 

Etiology and Bacteriology. — Weichselbaum first demonstrated 
that the pneumococcus of Frankel could cause primary broncho- 



392 DISEASES OF THE RESPIRATORY TRACT. 

pneumonia. His results have been confirmed by Cornil, Babes, 
and Neumann, the latter of whom found the pneumococcus in eases 
of primary bronchopneumonia. Quesiner and Neumann found the 
pneumococcus in the sputum of children suffering from broncho- 
pneumonia. 

The secondary form of bronchopneumonia may be caused by 
streptococci (Northrup and Prudden), which invade the lung-tissue 
from the trachea, as in diphtheria. Guarnieri also found streptococci 
in the lungs of children dying with bronchopneumonia after measles. 
On the other hand, these secondary types of bronchopneumonia may 
also be caused by the pneumococcus of Frankel, which causes the 
primary type of the disease. This has been shown in the work of 
Netter on the subject, and confirmed by Banti, Strelitz, and Baginsky. 
In diphtheria the Klebs-Loffler bacillus may be found in the lung 
areas of secondary bronchopneumonia (Babes, Frosch, Baginsky). 
The Eberth bacillus has been found in areas of bronchopneumonia 
complicating typhoid fever (Polyniere). 

Morbid Anatomy. — The essential lesion in bronchopneumonia is 
an inflammation of the walls of the bronchi and of the air-spaces 
surrounding the inflamed bronchi (Delafield). The walls of the 
bronchi are thickened and infiltrated with small round cells ; those 
of the alveoli of the lung are thickened and their cavities filled with 
fibrin, pus, epithelial cells, and new connective tissue. The smaller 
bronchi are dilated and contain pus, their walls being infiltrated. 
The inflammation may also be conveyed from the bronchi to the 
parenchyma of the lung by aspiration of secretion (Ziegler). In the 
latter case the smaller bronchi are occluded, collapse of the lung 
follows (atelectasis), and a pneumonia thus results. On section there 
are seen grayish-red, gray, or yellowish-gray areas of varying con- 
sistency, which correspond to a cut bronchus and its surrounding 
peribronchitic pneumonia. If the areas are croupous, they have a 
more granular appearance. Small areas of this form of pneumonia 
may coalesce, and thus whole lobules of the lung be consoli- 
dated. These larger areas may be separated by lung-tissue which 
contains air, or a whole lobe may become consolidated, as in lobar 
pneumonia. The exudate found in the affected alveoli is at first 
composed of desquamated swollen epithelial cells, and later of 
leucocytes. If the exudate has a more fluid character, it is called 
catarrhal. It then contains more serum than fibrin. If the fibrin 
is in excess, the exudate has greater consistency, resembling that in 
lobar pneumonia, and is then called croupous. The catarrhal and 
croupous forms of exudate may both exist in a lung affected with 
bronchopneumonia. Blood-cells may predominate in the exudate, 
so that the lung may on section have a hemorrhagic appearance. 
This is apt to be the case in streptococcus inflammation and also if 
foul fluids have been aspirated. 



BR OXCHOPXE I TMONIA . 393 

The mucous membrane of the bronchi is the seat of catarrhal 
inflammation. 

There is inflammation of the pleura to a varying degree. 

The bronchial and mediastinal lymph-nodes may be enlarged 

with simple or tuberculous inflammation. There is oedema of the 
lung tissue which is not inflamed. Bronchopneumonia may result 

in resolution and restoration to the normal. Suppuration and for- 
mation of abscess with destruction of lung tissue, or gangrene of 
the lung, may result in rare cases. 

Persistent bronchopneumonia in children results in induration of 
the lung. There is an increase of the connective tissue of the 
alveolar septa, of the walls of the smaller and larger bronchi, and 
also of the walls of the peribronchial vascular tissue. The lung on 
section is seen to be studded with fibrous nodules, or a whole lobule 
or lobe may be converted into connective tissue. 

Symptoms. — Bronchopneumonia is divided clinically into sev- 
eral distinct types. In newly born and very young infants the 
disease may set in insidiously. The infant is born in good con- 
dition ; after some little exposure it develops slight snuffles and a 
slight cough. Dyspnoea then appears. All this may occur within 
the first eight davs after birth. The cough becomes more harass- 
ing and the dyspnoea more marked. Slight cyanosis supervenes 
after a time. The infant is restless and does not sleep, the cyanosis 
becoming more marked and constant. The infant may have fre- 
quent convulsions. The dyspnoea finally becomes so marked as to 
cause distinct drawing inward of the lower part of the chest-wall 
with each inspiration. In these cases there is little or no tempera- 
ture ; in that respect they resemble cases of bronchopneumonia in 
extremely old people. The temperature may be slightly subnormal 
even when the infant is mortally ill with a disseminated broncho- 
pneumonia. The cough may not be marked. These cases should be 
differentiated from those occurring in infants born with an atelectatic 
condition of the lungs. In the class of cases under consideration, 
atelectasis develops as a sequence of the bronchitis and broncho- 
pneumonia. The movements are greenish, containing undigested 
curds. The infant- may finally develop enteritis. The course of 
the disease i- in these cases very acute. The infant either rapidly 
grow- worse or begins t<> improve immediately. The former course 
is, however, the rule in tin- very dangerous and insidious form of 
bronchopneumonia. If the infant does not improve, the cyanosis 
becomes more marked, as does also the dyspnoea ; the respirations 
increase to more than so a minute, the pulse becomes very rapid, and 
the heart feeble ; the infant lies in a soporose state ; the end may 
supervene with tympanites, convulsions, and oedema of the lung. 
This form of bronchopneumonia i- very frequently overlooked at 
tli.- outset and mistaken for a simple bronchitis. 



394 



DISEASES OE THE RESPIRATORY TRACT 



Another form of bronchopneumonia in infancy begins as a 
simple bronchitis, and may be treated as such for days. Finally, 
posteriorly in both lungs there are found the fine crepitations 
which give warning of the presence of bronchopneumonic pro- 
cesses. Bronchopneumonia of this variety runs its course without 
temperature. It occurs in rachitic or weakly infants and children, 
or follows a mild attack of influenza. The attacks of coughing 
are especially troublesome, and are frequently followed by vomit- 
ing of the contents of the stomach. The movements are loose,, 
and show greenish particles and undigested white flaky masses. 
The dyspnoea is constant and characteristic, and if the patient is 
out of bed, grows more marked toward the late afternoon. The 
ala? nasi are dilated. The temperature rarely rises above 
101° F. (38.3° C), and is generally 100° F. (37.2° C.) or even 
lower. The course is favorable ; the cough may persist for weeks 
after the subsidence of the acute symptoms, being especially marked 
at night. 

A more common form of bronchopneumonia in infancy begins 
as a simple bronchitis, which may last for a few days, when, with- 
out warning, the infant has a chill followed by a rise of tempera- 
ture, the case having suddenly developed into a full broncho- 
pneumonia. In a six weeks' old infant with disseminated patches 



Fig. 106. 


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Fatal bronchopneumonia : reinvasion of the lung on the fifth day. Infant, six months old.. 

of pneumonia, the chill was so severe as to cause extravasations 
of blood underneath the surface, with markings resembling those 
seen in marbling of the surface. In another case the chill was so 
severe that an immediate fatal issue was feared. In that broncho- 
pneumonia sometimes begins with a chill, it resembles a lobar 
process. 

The most common type of bronchopneumonia may begin with 
a rise of temperature preceded by vomiting. The harassing cough 



BRONCHOPNEUMONIA. 



395 



is present from the outset, causing the patients to cry with pain at 
each attack. There is no sputum, but in very young infants a 
frothy mucus may in the later stages of the disease collect about 
the mouth. The dyspnoea is marked. The alse nasi are dilated 
at each inspiratory effort. The peripneumonic groove is depressed, 
and in very severe dyspnoea the suprasternal regkm may also be 
depressed at each inspiration. Very frequently the dyspnoea will 
resemble that due to laryngeal stenosis. There are, however, 
none of the -ions of Laryngeal obstruction, such as laryngeal 
breathing. 

Fever is always present in infants and children, except in the 
classes of cases above noted. It may reach 10(5° F. (41.1° G), and 
is as a rule remittent. It may fall gradually to the normal, and in the 
favorable cases may reach the subnormal and remain there for a 
few davs. The course of the fever is, however, not an indication 





















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Ordinary type of bronchopneumonia. Recovery. 

of age. 



Female child, one year and six months 



of the severity of the disease. Fatal bronchopneumonia sometimes 
-how- a steady decline in the temperature toward the approach of 
the fatal issue. In other cases the temperature may drop to the 
normal, remain there a few hours or a day, and then rise sharply to 
K)4° F. (40° C.) or higher, thus indicating that a new part of the 
lung has been invaded by the disease (Fig. 106). Such rises of 
temperature after a fill to the normal are of grave import if they 
occur in an infant acutely ill with a process which has been severe 
for days. They -how a tendency of the process to spread, and in 
young weakly infant- such an extension of the process i^ apt to 
1) ■ fatal. A drop by lysis to a normal temperature which con- 
tinues for a few days, and i- followed by a slight gradual rise with 
subsequent remissions to the normal i- also common, and may 
indicate a return of the bronchopneomonic process, or a pleuritic 



396 DISEASES OF THE RESPIRATORY TRACT. 

effusion of a purulent character. The physician should be on the 
alert for an effusion in the cases which have run an irregular or 
remittent temperature for a period of more than two weeks. I 
have, however, operated upon cases of empyema following broncho- 
pneumonia in infants, in which the temperature-curve was normal for 
days, and then showed occasional rises to 101° or 102° F. (38.3° 

or 38.8° C.). 

The pulse is as a rule rapid. It is difficult in infants to estimate 
its exact character. It is, however, always possible to distinguish 
the abnormally weak and thready pulse even in the youngest infant. 
The rapidity of the pulse varies widely even in the favorable cases. 
Its ratio to the respiration (the pulse-respiration ratio) is, as a rule, 
maintained in favorable cases, but is not always so. JDven if it be 
so much distorted as to present the ratio of 1 to 2, the patient 
may make a good recovery. The character of the pulse and respira- 
tion should therefore be judged in connection with other signs of 
decreasing heart pow r er, such as abnormal pallor, coldness of the 
surface, and cyanosis however slight. In artificially-fed infants 
who are above the average weight, the beginning of cardiac weak- 
ness is indicated by an abnormal pallor of the face and slight cya- 
nosis of the lips. 

Sputum. — In young infants there is no sputum, nor is it probable 
that in uncomplicated cases of bronchopneumonia the younger in- 
fants cough up and swallow sputum, as is generally supposed. At 
most, there is after severe attacks of coughing a collection about 
the lips of frothy mucus probably coming from the trachea. 

Gastro-enteric Tract. — The symptoms referable to the stomach and 
intestine are of great importance in severe bronchopneumonia of 
the primary type. Even up to the second year of life tympanites 
sets in very early. In one case it was so distressing a symptom 
as to mislead the physician into thinking that peritonitis might be 
present. It is especially apt to set in with rachitic and weakly in- 
fants who have been fed on the bottle. If it appears late in a very 
sick infant, it is a symptom of grave import, and may sometimes 
cause the fatal issue. In some cases the pre-agonal distention is very 
extreme, and so far as can be judged very painful. Some infants 
begin to vomit from the outset of the pneumonia. The vomiting 
may occur once or twice in the twenty-four hours, or may be inces- 
sant. With the vomiting there may be the passage of greenish stools 
or a fully developed enteritis of severe type. So severe is the en- 
teritis in some cases as to cause the death of a patient suffering from 
pneumonia of only moderate severity. This form of the disease 
does not occur exclusively in the summer months, but is more preva- 
lent at that time. 

Cerebral Symptoms. — The infant is in some cases stupid from the 
outset of the disease. Older children may have slight convulsive 



BRONCHOPNEUMONIA. 397 

twitchings of tin. 1 muscles of the face and extremities. In eases in 
children at the third year there may be complete unconsciousness 
and symptoms simulating those of meningitis, such as rigidity of 
the muscles of the neck. I have seen the cerebral symptoms persist 
tor weeks in young infants who made complete recoveries. In other 
eases in young infants and children, the bronchopneumonia may 
partly resolve, and still there may be a continuance of the cerebral 
symptoms or even an exacerbation of them. In these cases the 
possibility of the presence of otitis or mastoid inflammation should 
l)i' seriously considered. 

The secondary form of bronchopneumonia may complicate the 
exanthemata — measles, scarlet fever, varicella, typhoid fever, per- 
tussis, influenza, and diphtheria, and also gastroenteritis or any form 
of infection, such as that of septic wounds or osteomyelitis. 

The symptoms of bronchopneumonia which complicates pertussis 
are of an unequivocal character. A febrile movement may be present 
with a simple brouchitis. If bronchopneumonia is imminent or 
present, the fever is marked and constant, and may reach 106° F. 
(41.1° C). The dyspnoea is very marked, but the cough may not 
be increased. In certain forms of pertussis without complications 
there is a slight constant dyspnoea, which is due to the disease. If 
bronchopneumonia is a complication the dyspnoea is more decided, 
the number of respirations three or four times the normal, and the 
pulse-rate increased. There is marked cyanosis. There may be all 
the symptoms of a severe bronchopneumonia, such as tympanites, 
vomiting, and green diarrhoea] stools. The bronchopneumonia is, 
as a rule, of the disseminated type, with areas of consolidation of 
greater or lesser extent in both lungs. The infants are much more 
ill than they would be with a primary process of the same extent. 
A bronchopneumonia of this kind can be diagnosed if upon exami- 
nation of the chest there are, in addition to the physical signs of 
bronchitis, fine crepitations over the different parts of the chest. 
especially over the lower lobes of both lungs posteriorly. There 
may also be dnlness with bronchophony and bronchial breathing over 
small areas, either in the upper or lower lobes of the lung on one or 
both sides. The bronchopneumonia <>f pertussis may supervene at 
any period of the disease, and is not the result of exposure. On 
the contrary, it may occur in infants and children who have been 
most carefully protected from exposure. It is the result of the form 
of disease — a mixed infection. The pertussis probably makes the 
lung more viable to disease in some subjects than in others. The 
bronchopneumonia i> a grave complication, and is very fatal. It 
may cause complications, such as pleurisy of a serous or purulent 
nature, and often open- the way for invasion of the lung by tuber- 
culosis. It may run a chronic course (persistent pneumonia) and 
reduce the patient to a very weak state. The patient will then 



39,8 DISEASES OF THE RESPIRATORY TRACT. 

develop consolidation of a whole lobe of the lung which will take 
weeks to clear up. 

Bronchopneumonia complicating measles supervenes, as a rule, in 
the stage of eruption, and is a very serious complication. Its pres- 
ence may be suspected if, on examination, of the chest, there are 
found, in addition to the rales of bronchitis, very fine crepitant rales 
over areas disseminated through both lungs. This complication also 
causes a febrile movement after the fading of the eruption. There 
are severe cough and dyspnoea. The pulse may reach 180 to 190, 
and the respirations 90, but the patient may recover even if the 
.signs of cardiac weakness, such as cyanosis, are marked. The 
patient is stupid, does not take food or notice his surroundings. 
Sometimes there may be other signs, such as hemorrhages into the 
eruption (so-called hemorrhagic measles), indicating that the process 
is one in which there is a mixed infection. There may be a com- 
plication of serous or seropurulent pleurisy. 

Bronchopneumonia complicating typhoid fever does not, as a 
rule, give very striking features apart from those belonging to the 
latter disease. It seems to be of a mild and insidious character. 
The bronchopneumonia of typhoid fever is apt to mask the typhoid 
if it appears at the outset of the disease. There is then a typhoid 
beginning as a pneumonia. The area of bronchopneumonia is well 
localized. It may be a small area in the upper or mid-region of the 
lung. The febrile curve in these cases may range quite high at the 
outset and thus mislead the physician. The process persists for 
weeks, sometimes as long as five weeks. The lung is slow in clear- 
ing up. The signs of clulness, bronchial voice and breathing may 
persist into convalescence. In other cases the pneumonia may 
supervene in the course of the disease. It can then be detected 
only if the cough is harassing and the dyspnoea marked. In deliri- 
ous patients the pneumonia can only be discovered by repeated and 
constant examination of the chest. These cases are not so apt to 
develop. pleurisy of a serous or purulent nature as the pneumonia 
complicating measles or scarlet fever. 

Varicella is only rarely complicated by bronchopneumonia. In 
this disease also the pneumonia runs a protracted course, but is less 
serious in its outcome than in the other exanthemata. It occurs in 
the severer forms of varicella in which the eruption is complicated 
with abscesses or necrosis of the skin (mixed infection). 

Scarlet fever is not so frequently complicated by bronchopneu- 
monia as measles, but when it does occur the bronchopneumonia is 
of a very severe type. It occurs in the septic forms of scarlet fever, 
and may appear early in the disease, on the fading of the eruption. 
Scarlet fever complicated by bronchopneumonia is frequently followed 
by pleurisy of a purulent nature. 

The bronchopneumonia which complicates diphtheria has been 



BRONCHOPNEUMONIA. 399 

carefully studied by Xorthrup and Prudden. It is the result of 
a streptococcic invasion of the lung or an invasion by the Klebs- 
Loffler bacillus. As a rule, however, it is a mixed infection, 
as was pointed out by Xorthrup and Prudden. The laryngeal 
form of diphtheria frequently proves fatal through this complica- 
tion. 

Of special interest is the bronchopneumonia which complicates 
chronic or subacute diarrhceal conditions. This form, which is of 
a distinctly septic type, is caused by infection of the lung by strep- 
tococci, which invade the general circulation through erosions in the 
mucous membrane of the gut (Booker, Czerny, Fischl). It is not 
always due, as was formerly supposed, to keeping the infant in the 
recumbent posture, nor does it occur in hospital practice alone, 
but is frequently seen in private practice in infants in unhygienic 
surroundings. It is of the persistent type, and runs its course with 
a daily high or low febrile curve, and results in areas of consolida- 
tion, which sometimes involve a whole lobe of a lung. This form 
of pneumonia is one of the fatal complications of the subacute intes- 
tinal catarrhs. 

Some infants, after one attack of bronchopneumonia, have repeated 
or recurrent attacks mi the least exposure (Fig. 108), in some cases 
developing catarrhal croup. In other cases, there develops an em- 
physematous condition of the lung, in which the least exposure or 
change in the atmosphere will cause an asthmatic attack. 

Course, Termination, and Complications. — Bronchopneumonia 
may terminate in complete recovery and restoration of the lung to 
the normal, or may prove fatal. The mortality varies at different 
times and with the environment. The prognosis in marantic infants, 
and also in bottle-fed infants, is very bad. Rachitic infants have 
bronchopneumonia with a very protracted course (Fig. 109). The 
form- which complicate measles, pertussis, scarlet fever, and influ- 
enza are very fatal. Abscess or gangrene of the lung may be a com- 
plication. Tn some forms of otitis the symptoms may very closely 
simulate those of tuberculous meningitis. Otitis prolongs the disease 
and frequently misleads the physician. Especially trying are the 
forms of bronchopneumonia of very limited extent in one or both 
lungs, in which, after the disease has run its course, there is a pro- 
tracted, remittent or intermittent fever-curve. Serous pleurisy and 
empyema are very common complications. Their presence may be 
suspected if the disease run- a course protracted beyond two weeks, 
and if signs, such asdulness, flatness, and bronchophony, persist and 
become more marked over the whole side of the chest. 

Meningitis may complicate the disease, (are should be taken not 
to confound cerebral symptoms with true meningitis. 

Pericarditis complicating bronchopneumonia is apt to be puru- 
lent, and i- rarely diagnosed during life. I have seen ca-cs \ n 



400 



DISEASES OF THE RESPIRATORY TRACT. 



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BR OyCHOPXE UMONIA . 401 

which during life repeated examinations failed to reveal positive 
signs of effusion into the pericardium, but in which purulent peri- 
carditis was found at autopsy. This is frequently true of cases in 
which the effusion is limited (30-50 grammes). If bronchopneu- 
monia occurs in the left lung with consolidation anteriorly and some 
pleural effusion, it is almost impossible to diagnose mdderatc peri- 
cardial effusion. The complication is very fatal. 

Physical Signs. — Clinically the physical signs of bronchopneu- 
monia are divided in those of the following stages : the first stage — 
invasion, the second stage — consolidation, the third stage — resolution. 
There is no sharp line of demarcation between the signs of the stages. 

First Stage. — Inspection shows the face to be flushed on one or 
both sides, and the nostrils to be dilated ; with each inspiration 
there is drawing inward of the peripneumonic groove and sometimes 
of the suprasternal tissues over the upper part of the trachea. 

Palpation. — If bronchitis is present, there may be rhonchal 
fremitus, but it is frequently absent. 

Percussion. — In the early stage, there is, just before consolida- 
tion, slight dulness over small areas, which in young infants with 
thin-walled chests may have a slightly tympanitic note (tympanitic 
dulness). Other parts of the chest may have a vesiculotympanitic 
note. 

Auscultation. — If bronchitis is present, the rales of bronchitis 
may be heard. The respiratory murmur is rude. By careful exami- 
nation of all parts of the chest one or more areas in which are heard 
fine crepitant rales may be found. They may easily be overlooked, 
and may disappear when the infant cries or coughs, and during the 
examination. 

Vocal resonance is slightly increased over areas in which there 
is slight dulness or the beginning of consolidation. The whole pos- 
terior aspect of the thorax from above downward, and also the axil- 
lary fossa, should be examined. The apex of the lung in front, and 
the lower part of the thorax in front and behind on both sides, 
should be carefully examined, as well as the areas of the borders of 
the lungs where they come in contact with the chest-wall. Increased 
vocal resonance and slight dulness alone, especially over the apex 
of the right lung in front and behind, should be accepted with great 
caution as indicative of the beginning of bronchopneumonia. 

Dyspnoea should not be looked upon as a sign of pneumonia. 
The crepitant rale in a circumscribed area or in several areas is 
the sign pathognomonic of this stage. 

Second Stage. — INSPECTION shows no condition differing from 
those of the first -tage. 

Palpation. — If the area of consolidation is limited, there is no 
change, because the area and the chest are small. If there 18 effusion 
in the lower portion of the pleural cavity, the fremitus may be dimin- 

2 ft 



402 DISEASES OF THE RESPIRATORY TRACT. 

ished over the lower part of the chest, although the pneumonia is in 
the upper part. Fremitus is therefore misleading, and is only con- 
firmatory in the presence of other signs. 

Percussion reveals dulness in complete consolidation or dulness 
with a tympanitic note in the beginning of consolidation, and also 
flatness if fluid is present over the consolidated area in the lower 
part of the lung. The dulness may involve a very small area or an 
entire lobe of the lung. There may be slight resistance to the per- 
cussing finger over the consolidated area. The unaffected lung is 
hyperresonant. 

Auscultation gives bronchophony and bronchial or broncho- 
vesicular breathing over the consolidated areas. These are not nec- 
essarily present over consolidated lung. In infants and children 
there may only be abnormally rude respiratory murmur and in- 
creased vocal resonance. Fine crepitant pleuritic rales may be 
heard over the consolidated area. 

Diagnostic stress is to be laid on complete dulness with bron- 
chophony and bronchial breathing. 

Third Stage. — Palpation will give increased fremitus if the 
area of lung consolidation is large and there is no fluid over the 
area. 

Percussion. — As in the first stage, there is dulness to a varying 
extent, with a tympanitic note showing the return of air into the 
lung. 

Auscultation gives a crepitant rale, as in lobar pneumonia. 
The voice and breathing are less bronchophonic. Dulness may 
persist for days or weeks. In some cases there is fluid, which 
increases the dulness or flatness. Dulness, crepitant rales, bron- 
chophony, and bronchial breathing are constant features, and are 
diagnostic. In infants and children, bronchophony is more con- 
stantly present than bronchial breathing. In the bronchopneu- 
monia of the newly born infant, it is sometimes possible to discover 
with the small bell of a stethoscope areas in which air does not 
enter (atelectatic). 

Equivocal Signs likely to be Mistaken for the Beginning of Broncho- 
pneumonia. — In infants and children, the physician is apt to be easily 
misled into a diagnosis of incipient bronchopneumonia. Equivocal 
signs — i. e., signs which are not absolutely diagnostic — are apt to be 
met in certain parts of the chest and in the presence of rational 
symptoms, such as fever or apparent dyspnoea, undue importance 
may be attached to them. These signs are as follows : 

a. A slightly high note on percussion and an increase of vocal 
resonance or fremitus, with a rude respiratory murmur on the right 
side over the apex in front or behind. It should not be forgotten 
that this region, especially in infants, normally shows varying degrees 
of these signs as compared with the left side. 



BROXCHOPXE UMONIA . 403 

b. A slight dulness over the lower part of the chest on the right 
side behind, due to the presence of the liver, is normal. To be 
abnormal, the dulness must be very marked and the vocal resonance 
much inereased. The resistance to percussion must be pronounced 
in order, in the absence of more positive signs, to justify a sus- 
picion of the beginning of consolidation. 

c. Bronchial or bronchovesicular breathing too near the vertebral 
column behind on either side, between the scapulse, should be cau- 
tiously interpreted. In some infants, the breathing in this region 
is normally bronchovesicular. It is in this region that the diagnosis 

© © 

of central pneumonia is so often made — a diagnosis rarely verified 
by the subsequent course of a case. 

d. In some infants and children, especially from six to ten years 
of age, it is found that the fremitus and vocal resonance diminish 
behind from a short distance below the augle of the scapula to the 
base of the lun^ ; the breathing also is heard less distinctly. A 
diagnosis of incipient pneumonia or consolidation with fluid re- 
quires positive and unmistakable evidence very low down behind. 
The thick muscles of the back and organs behind the thorax, such 

as the kidney and liver, obscure slight signs below the ninth or 

© © 

tenth rib. Slight variations from the normal should not receive 
undue attention. 

Diagnosis. — Bronchopneumonia should be differentiated from 
the lobar fibrinous form of the disease. In children above five 
years of age this is not difficult ; in those under the second year, 
in whom fibrinous or lobar pneumonia is not uncommon, a posi- 
tive diagnosis of lobar pneumonia cannot be made until the stage 
of consolidation, and even at that time only as to distribution. In 
the main, it is made from the course of the temperature. In lobar 
pneumonia the temperature will fall by crisis after the usual period. 
A marked leucocytosis, which increases toward the day of crisis and 
then rapidly diminishes, is also a characteristic feature. There 
should be also the physical signs of lobar consolidation. 

If these symptoms and signs are all present, it may be assumed 
clinically that a lobar pneumonia is to be dealt with. Such a diag- 
nosis is always open to doubt, for a bronchopneumonia may have 
tin- lobar consolidation and the leucocytosis, but will rarely have the 
critical drop of temperature which occurs in lobar pneumonia. As 
to the onset, bronchopneumonia may set in with a chill, and lobar 
without one. The complications in both forms are identical ; 
empyema i- as likely to occur in one as in the other. Lobar 
pneumonia i- rarely prolonged in duration if complications are 
absent, while the bronchopneumonic type of disease is, as a rule, of 
longer duration and may be prolonged into a chronic course. 

Disseminated patches of consolidation in a lung in which there 
i- general bronchitis point to bronchopneumonia; diffuse bronchitis, 



404 DISEASES OF THE RESPIRATORY TRACT. 

with fine crepitations in the lower lobes of both lungs, to broncho- 
pneumonia. The presence of a primary disease — measles, scarlet 
fever, typhoid fever, and influenza — will also influence the process 
in the lung. The secondary pneumonia is a bronchopneumonic 
process. 

Prognosis. — The mortality of bronchopneumonia, even under 
the favorable conditions of private practice, is as high as 25 per cent. 
In hospital practice it is much higher, and may reach 50 per cent, 
or more. It is increased in bottle-fed, rachitic, prematurely born, 
and syphilitic infants, and is greatest in the first year of life. The 
disease is especially fatal in newly-born infants, and in cases of 
gastro-intestinal disorder. The mortality rate increases in New 
York City in the months of December, January, and February, 
during which the weather is alternately moist, warm, and cold. 
Certain years show an increased mortality because of the severe 
nature of the epidemic. 

At the bedside, a prognosis is based on the condition of the lung, 
temperature, heart, and the presence or absence of nervous symptoms. 
A persistently high temperature, if there are areas of consolidation 
in both lungs, is of serious import. An abnormal pallor or slight 
cyanosis in a bottle-fed baby, even if well-nourished, is a danger 
signal. Forced and irregular action of the diaphragm is serious ; 
marked drawing inward of the sides of the chest, sometimes as high 
as the eighth rib, is a very unfavorable sign in infants. These cases 
show a depression of the suprasternal notch as marked as that 
which occurs in laryngeal obstruction. Eepeated convulsions and 
jaundice, with enlargement of the spleen, in rachitic infants indicate 
intense toxaemia. These cases are fatal. Marked tympanites at the 
end of the first week, in connection with diarrhoea and weakness of 
the heart, is an unfavorable symptom. Dyspnoea with respirations 
irregular in rhythm and depth denotes diffuse involvement of both 
lungs, and is present in the unfavorable cases. Cerebral symptoms 
supervening late in the disease are unfavorable. 

The favorable signs are a good muscular quality of the first sound 
of the heart, red lips and warm surface, good reaction after hydro- 
therapy, and periods of quiet sleep with full noiseless breathing, 
movements of the bowels normal or slightly green, and an absence 
of marked tympanites. Caution should be exercised in making any 
prognosis in a bronchopneumonia which shows a marked tendency 
to involve new areas of lung. 

In the treatment of bronchopneumonia of infants and chil- 
dren, it should be borne in mind that the disease is a self-lim- 
ited, acute, infectious one, and that there is no remedy which can 
abort it or prevent complications. As in lobar pneumonia, the 
ill effects of the disease must be counteracted as much as possible 
and the strength of the patient supported. Since the patients are 



BR OS CHOPS E I TMONIA. 405 

of very tender age, remedies which are powerful in their ultimate 

effects are to be carefully avoided. The indications in the treatment 
are to counteract the effects of the temperature and to support the 
heart. 

The temperature in the most fatal forms of tins disease in new- 
born infants is below the normal at times, and rarely reaches a very 
high point. In other cases of bronchopneumonia in older infants 
and children, it remains persistently above 103° F. (39.7° C). In 
these eases, as in lobar pneumonia, the various forms of hydrotherapy 
are utilized. Of all the methods, the cold compress applied to the 
chest, as before described, seems to be the most efficacious. Com- 
presses lower than 70° F. (21.1° C.) are not applied. The appli- 
cations may be renewed every hour, if the patient bears them well. 
It sometimes happens that a compress wrung out in water at 70° F. 
(21.1° C.) will depress the patient, causing cyanosis wthout reaction. 
In such cases, as in the lobar cases, I have found the warm bath, 
10")°-107° (40.3°-41.f>° C), of the greatest utility in relieving the 
nervous symptoms, such as restlessness and convulsive twitchings. 
Infants, as a rule, will not bear baths below 80° F. (26.6° C). I 
therefore do not utilize the cold full bath in bronchopneumonia in 
infants. I do not think it advisable to use the bath at 90° F. 
(32.2° C.) or higher, with cold douching of the head and shoulders, 
to obtain reaction in infants. The procedure rouses the patients only 
momentarily, and the subsequent depression is greater. Cold packs 
over the whole body are also heroic remedies, but are advocated by 
some authors. 

The heart is supported by means of digitalis, strychnine, camphor, 
musk, caffeine, and ammonium carbonate. Of these agents, the most 
useful are digitalis, strychnine, and musk. 

Digitalis is administered in the form of the tincture. A drop is 
given for every six months of the age of the patient. It should 
not be used unless the pulse is high, and should then be given 
every three hours. It is discontinued after being administered 
for two or three days. The effects of stronger preparations, such 
as the fluid extract, cannot be gauged so carefully as those of the 
tincture, and they are therefore less useful. The cases in which 
digitalis is of the greatest value are those in which there is cya- 
Dosis to a mild degree, or excessive pallor denoting great cardiac 
weak i, 

Strophanthus may be administered alone or in combination with 
digitalis. The tincture is the form generally used. 

Strychnine i- one of the most useful drugs in the treatment of the 
heart. An infant six months old will bear grain ., I lp or -yj-fl- (0.0003 
or 0.00025) very well. Older infant- and children bear grain y-J-g- 
(0.0004) quite well. Strychnine should not be used in cases where 
there i- excitability of the nervous system. 



406 DISEASES OF THE RESPIRATORY TRACT. 

Atropine, which is so useful in adults, is not well borne by in- 
fants and children. 

Ammonium carbonate is one of the most useful drugs when for 
any reason digitalis cannot be used. Convulsions or restlessness 
are treated with the bromides of potassium and sodium, which may 
be combined. Chloral hydrate is combined with both, especially 
where one dose of bromide of potassium and chloral hydrate is 
given per rectum. 

I do not use poultices. Some authors use them as a routine 
measure. 

Inhalations of benzoin and turpentine are of- little efficacy. 
They do not affect the local lesion in the lung, nor do they act on 
the mucous membrane as they do in catarrhal processes of the nose 
and throat. In some cases I have seen harm result from overload- 
ing the atmosphere with the odor of balsams. 

The patient should be isolated from the healthy children of 
the family and the room kept at a temperature of from 68° to 
70° F. (20° to 21.1° C.) and well ventilated. An open wood fire 
is the most satisfactory method of heating and ventilating the sick- 
room. 

In threatened oedema of the lungs I have found, as in lobar 
pneumonia, that the right ventricle is best relieved by nitro- 
glycerin, grain -^^ to T ^ (0.0003 to 0.006) being given at a dose, 
and by the constant administration of oxygen containing 20 per 
cent, of nitrous oxide. 

Whiskey is so universally used that the mode of administering 
it should receive special mention. Alcohol should not be used as a 
routine remedy. In some of the milder cases its use is superfluous. 
There are other cases in which its use must be suspended because 
of the constant vomiting. In the severer types of bronchopneu- 
monia, in which the temperature is persistently high, the effects of 
the toxaemia may be counteracted by administering whiskey. In- 
fants receive from minims xx to xxx (1.2 to 2.0) ; older children 
a drachm (4.0) every three hours. The whiskey should be well 
diluted, and should be given after the nursings. 

The feeding of infants who take a substitute for the breast should 
be carefully watched, especially in bronchopneumonia, a disease in 
which diarrhoea is apt to supervene. If diarrhoea is present, the milk 
should be discontinued and a cathartic given. The infant is given 
a high rectal injection of warm normal saline solution twice daily, 
and is kept on solutions of egg-albumin and acorn cocoa until the 
intestinal symptoms subside. Milk is then again given. In these 
cases of intestinal disorder it is of the utmost importance to see 
that the milk is fresh and uncontaminated. 

The cases not complicated by diarrhoea are given a warm high 
rectal enema of the normal saline solution once daily. In infants, 



PERSISTENT BRONCHOPNEUMONIA. 407 

this procedure will ward off tympanitic distention of the abdomen 
and stimulate the heart. 

The cough is sometimes very harassing, and then only should be 
relieved. The camphorated tincture of opium or the wine may he 
given in moderate doses. Codeine is useful in older children; 
morphine should not be used. In the many hundreds of cases 
which I have treated I have not found it necessary to use it. Strap- 
ping the chest to relieve pain is harmful in infants and children. 
The chest in these subjects is resilient, and any limitation of its 
action reacts unfavorably in preventing a full expansion of the 
unaffected lung. 



PERSISTENT BRONCHOPNEUMONIA. 

( Chron ic Bronchopneumon i i. ) 

Persistent bronchopneumonia is a distinct type of bronchopneu- 
monia the course of which extends over weeks or months, the patient 
meanwhile becoming much reduced in flesh and strength. These 
cases occur in weakly infants, usually in those who are bottle-fed. 
A distinct type of the disease complicates chronic enteric catarrh. 
Oases of this class belong in the category of Gastro-Intestinal Sepsis 
of Fischl, Escherich, and Czerny. Cases of another set complicate 
and follow pertussis, measles, and influenza. Lastly, there is a true 
tuberculous form which is not strictly included in the above classi- 
fication. The condition is thus rarely primary. 

Symptoms. — The infant or child has at first the symptoms of an 
ordinary bronchopneumonia. The fever, however, is of longer 
duration than in cases which recover. Cases of gastro-enteric affec- 
tion or pertussis will continue to have a remittentlv high tempera- 
ture, which may reach 105° (40.5° C), but fall to* 101° or 100° 
38.3° or 37. 7° ( '. ) on the same day. It will remain normal for 
days, and then rise again, as indicated in the chart (Fig. 110). 
There are cough, -light dyspnoea, emaciation, and gastro-intestinal 
disturbances. In cases of enteric catarrh the intestinal disease 
take- clinically a secondary place. Some of these cases eventually 
recover in spite of the progressive emaciation and high fever. 
Tin- i- especially the case in persistent bronchopneumonia which 
complicates pertussis. 

The Blood in Persistent Bronchopneumonia with Recurrent Invasions. 
— In the case fr<»in which the chart was taken there was a distinct 
increase of the number of Leucocytes with each new rise of tempera- 
ture and fresh invasion of the lung. The Dumber of leucocytes 
mounted a- high ;i- 80,000 to the cubic millimetre. A differential 
count showed that the polynuclear neutrophiles ranged at different 
times from 7-*> to 82 per cent, of the leucocytes and the small 



.408 



DISEASES OF THE RESPIRATORY TRACT. 





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lymphocytes (mononuclear) from 13 
to 21 per cent. As the disease pro- 
gressed, there were also signs of ex- 
treme anaemia, microcytes, megalo- 
cytes, and poikilocytes being present. 
Physical Signs. — On examination, 
there are found areas of consolidation 
of varying extent, generally made out 
posteriorly over the apex or toward 
the base of the lung. There are signs 
of general bronchitis, increase of fre- 
mitus, and dulness marked, slight, or 
combined with a tympanitic note. 
There may be fine crepitations here 
and there over the chest. If the 
areas are extensive, there may be 
bronchophony or bronchial breathing. 
The complete consolidation of prim- 
ary bronchopneumonia is not always 
present. The lung is only partially 
consolidated, so that the vocal reson- 
ance may simply be markedly in- 
creased or the breathing may be 
bronchovesicular. 

Diagnosis. — Persistent broncho- 
pneumonia may be suspected if there 
is an area of dulness at the apex of 
one lung which does not resolve after 
a lapse of weeks. In these cases, there 
are the other signs of partial or com- 
plete consolidation at the apices, the 
base of the lung continuing resonant 
in the absence of signs of pleurisy. 
The persistence of fremitus on the 
affected side, especially in the mid- 
region of the chest behind, will aid in 
excluding the presence of fluid. The 
rest of the lung is in these cases res- 
onant or hyperresonant. In doubtful 
cases the exploring-needle should be 
introduced into the chest to ascertain 
whether fluid is present. 

The treatment is practically an 
extension of the treatment of the 
primary condition. If there is an 
affection of the gastro-enteric tract,. 



DRY PLEURISY. 409 

it is treated. If there is pertussis, treatment proceeds on the lines 
usually followed in that affection. In some eases the administration 
of iodide of potassium in small doses has seemed to have a bene- 
ficial effect on the course of the process in the lung. 



PLEURISY. 

{Heurilis.) 

Pleurisy in infancy usually occurs as a secondary disease ; it is 

rarely primary. 

Dry pleurisy is the form in which the pleura is inflamed without 
any appreciable formation of exudate in the pleural cavity. 

Pleurisy with effusion, or subacute pleurisy, as it is incorrectly 
called, is the form in which a serous or serofibrinous effusion is found 
in the pleural cavity. The form in which the effusion is of a sero- 
purulent or markedly purulent character is also called empyema. 

Empyema is therefore a purulent or suppurative pleurisy. There 
are other forms of pleurisy which occur with neoplasms of the lung 
or pleura?. These are not discussed in this section. 

Dry Pleurisy. 

Frequency. — Dry pleurisy, pure and simple, is, in my experience, 
clinically not common among infants and young children. As an 
independent affection, it is found more frequently after the fifth year 
of life. Clinically, the cause of this infrequency in infancy cannot 
be easily explained. Young infants and children rarely indicate 
the pain which is the leading symptom. The disease is masked by 
other symptoms occurring at the same time. Older children locate 
the pain and direct attention to it. 

Etiology. — This form may be primary or secondary. As a 
primary affection it is found in rheumatic subjects, especially those 
who are or have been subjects of disorders such as endocarditis or 
fibrinous adhesive pericarditis. In these cases the etiology is the 
same as that of rheumatism. The condition is secondary to pneumo- 
nia. It may be found complicating any of the infectious diseases — 
influenza, scarlet fever, measles, typhoid fever, or tuberculosis. In 
Buch cases the bacterial factor in the etiology is much the same as in 
the form- which will be considered under Pleurisy with Effusion. 
Pleurisy may complicate nephritis of the subacute or chronic type. 
Traumatism will cause this form of pleurisy ; exposure to cold or 
wet will predispose to it. 

Symptoms. — The cases of simple dry pleurisy not proceeding to 
the formation of effusion in the pleura, which have come under my 
notice, gave few symptoms. 






410 DISEASES OF THE RESPIRATORY TRACT. 

Pain. — The children in the majority of cases complained of dis- 
tinct localized pain on exertion or on breathing deeply. There is 
also some local pain on external pressure. I have seen marked pleu- 
risy of the dry form in which pain was absent. This is most likely to 
occur in pleurisies secondary to nephritis. In the primary type, the 
patients continue to walk about, but are pale and have an anxious 
expression of the face. There is sometimes a rise of a degree or 
more in temperature and the respirations are increased and super- 
ficial. Those forms described by Henoch as setting in with convul- 
sions, high fever, and vomiting, have not in my experience remained 
dry fibrinous pleurisy, but have proceeded to the formation of effus- 
ion in the chest. The duration of dry pleurisy is variable, and in the 
rheumatic forms may extend over a long period of time. 

The diagnosis is not difficult, and is made from the physical 
signs and the history. On examination, a localized area over which 
there are a large number of dry crepitant rales is found. The 
rales are heard so close under the ear that they are distinguishable 
from the crepitant rales of pneumonia. In some cases there is a 
dry rubbing sound — a pleuritic friction — over the area affected. In 
the cases without complications there are no other signs. There is 
little or no dulness and no change in the voice or breathing-sounds. 

The prognosis is very good. Tuberculous disease of the lung 
is not a causative agent in these cases in children so frequently as 
in the adult. The primary dry pleurisies, with proper care, sub- 
side and gradually disappear. 

The treatment of dry pleurisy is very simple. If the subjects 
are rheumatic, they are put on small doses of salicylate of sodium. 
The bowels are kept open with a saline cathartic, preferably Carls- 
bad salts. The patients are kept in bed. It is not advisable to 
strap the chest to relieve pain. The desired relief can be secured 
by some local application of iodine or a sinapism. Codeine is 
administered in moderate doses to relieve the cough and pain. 



Pleurisy with Effusion (Subacute Pleurisy) and Empyema. 

{Purulent or Suppurative Pleurisy.) 

Frequency. — This form of pleurisy is common in infancy and 
childhood. The largest number of cases occur before the fifth year 
(Simmonds). The succeeding five years show the next greatest 
frequency. Israel found 29 per cent, of 206 cases to be purulent. 
Mackey estimates the purulent cases at 40 per cent, of the whole num- 
ber in children, as against 5 per cent, in adults. Combiuing the 
statistics of Simmonds and Hofmokl of Vienna, this form is found 
to have greater frequency in the male sex. According to these authors, 
the left side is more often the seat of the disease. Simmonds found 



PLEURISY WITH EFFUSION AND EMPYEMA. 411 

the disease to be bilateral in only 7 out of 175 eases. Of 120 of 
my own eases of empyema, 2 were bilateral. Of these 120 cases, 
104 occurred before the fifth year, and 16 between the fifth and 
tenth years ; 39 were between the age of one and two years, and 
16 were less than twelve months of age. The youngest patient was 
two months of age. 

Etiology. — Primary pleurisy, whether suppurative or serous, 
is rare. The literature contains eases of acute effusion in the pleural 
cavity, in which there was apparently no exciting cause or primary 
lung affection. The etiology must in such cases remain in doubt. 
Infection may take place through so many avenues that it is difficult 
to point out the mode of entrance. 

Pleuritis, serous or purulent, is generally secondary in infancy 
and childhood. All forms of lobar or bronchopneumonia may give 
rise to pleurisy, most of the eases being traceable to this source. 
The infectious diseases — measles, scarlet fever, pertussis, typhus 
and typhoid fever, diphtheria, forms of tonsillitis, retropharyngeal 
and mediastinal abscess, may precede or directly cause an attack 
of pleurisy. Chronic intestinal sepsis may cause empyema. In 
the latter case a pneumonia generally precedes the pleurisy or is 
present at the same time. In sepsis of the newly-born infant, 
there may be a complicating empyema. Osteomyelitis of the septic 
streptococcus variety may be complicated by purulent pleurisy. 
Tuberculous disease of the lung, actinomycosis of the lung, abscess 
of the liver, abscess in the mediastinum and abscess in the abdom- 
inal cavity involving the viscera, may cause pleurisy. Appendicitis 
may after the formation of abscess cause pleuritis by extension of 
the process along the coils of gut to the diaphragm. Finally, rheu- 
matism may cause pleurisy of a serofibrinous nature. Exposure to 
cold and wet is undoubtedly a predisposing cause. In children, it 
is common to have a history of a fall or a blow occurring just prior 
to the attack of pleurisy. 

Morbid Anatomy. — Pleurisies which accompany acute pneumo- 
nia are the most frequent. In these, there may be a slight injection 
of the pulmonary pleura and a loss of the normal lustre. Here and 
there a tew fibrinous threads or adhesions may be found coursing 
over the surface <>t* the pleura or running from the costal to the pul- 
monary pleura (dry or fibrinous pleurisy (pleuritis sicca)). In other 
cases, there is a thickened condition of both pleural reflections, caused 
by the deposit of fibrin on the surface. Sometimes the amount of 
fluid is small, while the pleura is very much thickened. The pleura 
itself may be little altered ; underneath the fibrin, the lymph-spaces 
and blood-vessel- may be dilated. In some cases there is also a serous 

or seropurulent exudate containing leucocytes, endothelial cells, and 
bacteria. The fluid may be clear or bloody, turbid or opaque, 
yellow or greenish, and thin or creamy in consistency. Large clots 



412 DISEASES OF THE RESPIRATORY TRACT. 

of fibrin may be found floating in the exudate. Adhesions may 
form pseudo-encapsulations of exudate, binding down the lung and 
preventing its expansion. In children, however, the tuberculous 
pleurisies are most likely to cause extensive thickening of the 
pleura. In addition to the deposit of fibrin on the costal and pul- 
monary pleura, there is a real inflammatory thickening of the tissue 
of the pleura itself, with a deposit of tubercle tissue. Serous or 
purulent exudate is encapsulated by adhesions, while the lung is 
bound down by layers of inflammatory tissue. In the tuberculous form 
the changes are progressive. In the acute inflammatory forms, the 
exudates are absorbed and the fibrinous deposit is organized into new 
connective tissue. In time the pleura may be restored to the normal. 
Adhesions, however, form an important factor in acute pleurisy of 
children. The pleura may in some cases be permanently thickened 
by a new layer of connective tissue persisting throughout life. There 
are forms of pleurisy not tuberculous in which this thickened con- 
dition not only remains, but extends from the pulmonary pleura into 
the lung along the interlobular tissue of "the lung itself. There are 
induration and destruction of lung tissue. This induration is seen 
in connection with persistent bronchopneumonia. The amount of 
eifusion (purulent) is sometimes quite large in children, and may 
reach 1000 to 5000 cubic centimetres (Simmonds, Hofmokle). In 
scurvy and morbus Werlhofii, blood may be effused into the pleural 
exudate. 

Bacteriology. — Pleurisy or empyema is divided into several 
groups according to the class of bacteria found in the exudate. It 
is well established that the bacteria are the essential cause of the 
disease. 

The first and largest group is that in which the pneumococcus of 
Frankel, the lanceolate diplococcus, is found. These cases are called 
metapneumonic. They may occur during the progress of a pneumo- 
nia or after it has run its course. In some cases the process in the 
lung plays clinically a secondary role. The pneumococcus seems to 
occasion very little disturbance in the lung and to spend its force on 
the pleura. Thus within three days after the initial chill the pleura 
is filled with serous or seropurulent fluid, better found that of 28 
pleurisies in infants and children 53 per cent, were due to the 
pneumococcus. In 71 cases of empyema I found the pneumococcus 
by culture in 49 (69 per cent.). 

The second group comprises those cases in which the streptococcus 
alone, the staphylococcus, or the streptococcus with the pneumo- 
coccus or staphylococcus, is found, better found that 17 per cent, 
of his cases were of the streptococcus class ; 15 per cent, of my cases 
were due to this micro-organism. In cases of the septic type, such 
as complicate sepsis of the newly born or osteomyelitis, or follow 
scarlet fever, the Streptococcus longus is found in the exudate. 



PLEURISY WITH EFFUSION AXD EMPYEMA. 



413 



These eases are severe. Nine per cent, of my eases were caused by 
the staphylococcus. In 1> per cent of my eases of empyema the 
streptococcus and pneumocoocus were both found in the exudate. 
Although the pleurisies in which the streptococcus and staphylococcus 



Fig. 111. 



Fig. 112. 



\ 



\ 



> 



\ 




Fig. 113. 



Fig. 114. 




Fie. 111.— Streptococci from the pas of empyema; pure culture. i<xhi. Photomicrograph. 
Fig& 112 and 113.— Pneumococci Diplococcua lauceolatus) from the pus of empyema. Cover- 
glass preparations Bhowing capsule. Photomicrograph. 1000. 
Fig. 114.— Pneumococci Diplococcua lanceolatue ; pure culture from the pus of empyema. 

Photomicrograph. 660. 

are found may follow a pneumonia, they may also be secondary to 
a follicular amygdalitis, the exanthemata, typhoid fever, influenza, 
diphtheria, sepsis, and osteomyelitis. 



414 DISEASES OF THE RESPIPATORY TRACT. 

The third group of cases comprises those in which either the 
tubercle bacillus is found in the exudate, or the exudate is free from 
micro-organisms. The latter condition is frequently presumptive 
evidence of a tuberculous infection (Ehrlich). The tubercle bacillus 
was found in one of my 72 cases of empyema, while in 3 the 
findings both by cover-glass spread and culture were negative. This 
would at most give a frequency of 6 per cent, for the tuberculous 
variety of pleurisy or empyema. 

The last group is that in which micro-organisms other than those 
mentioned are found in the pleuritic exudate. Such cases have been 
observed in connection with typhoid fever in which the Eberth 
bacillus has been found. Escherich has found the coli bacillus in a 
case of empyema. I have seen one case of this kind. The bacillus 
of the saprophytic variety and that which causes a putrid empyema 
are found in cases of this fourth class (Koplik). 

The following table shows the relative frequency of the various 
forms of pleurisy and empyema with the varieties of bacteria in the 
exudate : 

Children. Adults. 

Netter Koplik 

28 cases. 72 



Pneumococcus 53.6 per cent. 60 per cent. 17 per cent. 

Pneumococcus and Streptococcus 3.6 " 9 " ' 2.5 " 

Streptococcus 17.6 " 15 " 53 

Staphylococcus 9 " 1.2 " 

Putrid 10.7 " 

Tuberous 14.3 " 7 " 25 

The most important fact to be deduced from the statistics is that 
while tuberculous pleurisy in children has a frequency of 6 per cent., 
adults show a much greater frequency, many of the streptococcus 
cases being tuberculous in the latter subjects. This figure added to 
the number of cases in which tubercle bacilli are found in the exu- 
date would bring the frequency in the adult to at least the 45 per 
cent, given by Bowditch as the relative figure. 

The physical characteristics of an effusion in the chest are of 
clinical importance. An effusion if purulent has usually the gross 
physical characteristics of ordinary pus. In some cases the effusion 
is at first clear and serous, but is subsequently seen to be purulent 
without the occurrence of any extraneous infection. In other cases 
the effusion may be a cloudy serum, which on exploratory punct- 
ure is after a few days found to be purulent. In rare cases the 
effusion or exudate in the pleura is hemorrhagic. An effusion of 
that character has not the same significance in children as in adults. 
In the latter such effusions may be tuberculous or due to some morbid 
growth of the pleura ; this is not necessarily the case in children. 
I have had a number of cases of hemorrhagic effusion into the 
pleural cavity. In none of them was there a tuberculous element. 



PLEURISY WITH EFFUSION AND EMPYEMA. 



415 



In all, streptococci were found in the effusion, and in some the 
admixture of blood could be traced to a scorbutic tendency. In 
one ca>e, in an adolescent with localized effusion of a hemorrhagic 
nature, there was an actinomycosis of the pleura and lung. The 
history of this case was not that of an effusion of an acute, but of a 
subacute chronic nature. 

Symptoms. — There are no symptoms characteristic or pathog- 
nomic of effusion in the pleura or empyema. The condition is in 
most cases masked by the symptoms of the causal affection. Cases 
following a pneumonia set in with a chill or a rapid rise of tem- 
perature, with which there may be a convulsion followed by stupor 
or cerebral symptoms. After this onset the fever continues, rang- 
ing from 103° to 105° F. (39.4° to 40.5° C), the pulse being 140 
to 180. There will be cough, great dyspnoea, and pain in the chest, 
which is especially manifest when the infant or child coughs. The 
breathing is shallow. After a few days the acute symptoms sub- 
side, the fever becoming remittent. The temperature may be nearly 
normal. The dyspnoea continues, although the temperature and 
pulse may be normal during part of the day. 



Fig. 115. 



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Lobar pneumonia : fall of temperature, by lysis: gradual rise after the thirteenth day, due 
to empyema. Operation on the nineteenth day. Recovery. Boy, four years of age. 

In some of the cases the effusion becomes apparent on the 
eighth day ; in others a purulent effusion is found in the chest on 
the twelfth or fourteenth day of the disease. The effusion, which 
finallv becomes apparent in the chest, has been coincident in its 
onset with a pneumonia — there has been a pleuropneumonia. The 
process in the lung, however, takes a secondary place in the clinical 
picture when the eflusion in the pleural cavity has accumulated. 

There is another set of cases in which the course of the disease 
i- insidious. The patient may at the onset have had for two <>r 
three days a febrile movement which has subsided, leaving the child 
not quite well and with a slight febrile movement toward evening, 
a slight hacking cough, and some little pain in the chest on exertion. 
Langour and loss of strength are progressive. There may be ex- 



416 



DISEASES OF THE RESPIRATORY TRACT. 



Fig. 116. 



hausting sweats at night. Examination of the chest will reveal an 
effusion. 

The metapneumonic pleurisies in infants and children have a 
characteristic course. The patient has a typical pneumonia. The 
temperature on the ninth, tenth, or thirteenth day may drop to the 
normal or subnormal, the respirations continuing high. A gradual 
rise of temperature follows, with physical signs of fluid in the chest 
(see Fig. 115). The pulse and respirations rise with the temperature. 
Toward evening there may at times be chilly sensations. Explora- 
tion may discover fully developed effusion in the chest, serous or 
purulent according to the severity of the pleuritic infection. As a 
rule the younger the subject, the more likely is the effusion to be of 
a purulent nature. The duration of the effusion in the chest will 
also be a guide in determining its nature. An effusion occurring 
after pneumonia in a young infant and persisting for a week after 
the pneumonia has run its course, is likely to be purulent. 

Diagnosis. — There are some symptoms, such as continued 
dyspnoea, a slight or troublesome cough, exhausting sweats, and a 
distinctly intermittent range of temperature, which in all cases of 
pleurisy should direct attention to the chest. None of these symp- 
toms is, however, pathognomonic of pleurisy, serous or purulent, 

since they may be found in other pul- 
monary conditions. The diagnosis of 
pleurisy with effusion or empyema should 
take into consideration not only the 
rational symptoms, but also the physical 
signs. 

The physical signs of pleurisy with 

effusion and of empyema are identical. 

Fluid in the Chest. — A. The 

chest partly filled with fluid. B. The 

chest full of fluid. 

A. The Chest Partly Filled with 
Fluid. — It is assumed that the greater 
part of the fluid is in the lower portion 
of the chest (Fig. 116). In children 
and infants it does not cause displace- 
ment of the viscera. 

Inspection may show fulness of the 
lower part of the affected side; the 
lower part of the chest moves less than 
the normal side. 

Palpation. — Vocal fremitus will be felt over the upper portion 
of the chest in front or behind, and will be lost over the lower 
portion. 

Percussion of the chest in front will often give an exaggerated 




Pleural cavity parti v filled with 
fluid. 



PLEURISY WITH EFFUSIOX AND EMPYEMA. 417 

hyperresonant tone over the upper lobe of the lung. Behind, there 
is almost always dulness to a greater or loss degree above over the 
scapula, due either to thickening of the pleura or to an exceedingly 
thin layer of fluid. This dulness can be distinguished from dulness 
due to other causes by firm percussion which will elicit the pulino- 
narv note of the underlying lung. Below, over the fluid, the 
dulness changes to complete flatness. 

Auscultation. — The voice and breathing may be heard over the 
whole side with as much intensity as on the healthy side, or with 
diminished intensity below the level of the fluid. Kales, generally 
pleuritic crepitations, may be heard above the level of the fluid. 
Bronchial breathing and voice may be heard over the fluid or at the 
level of the fluid, but this sigo is not absolute. 

Diagnosis to justify needle exploration must be based on absence 
of vocal fremitus over the fluid and its presence above the fluid, 
dulness behind above the fluid, which on firm percussion gives a faint 
pulmonary tone and flatness over the fluid with slightly increased 
resistance to the percussing finger. 

Nate, — The method of examining infants for fluid is invariably 
that indicated in the earlier part of the book. It is a mistake to 
examine the infant as it lies in the lap of the mother, for in this 
position the fluid will gravitate behind. When the infant lies on the 
face, the fluid will again gravitate to the anterior part of the chest 
and thus not be made out. In the earlier stages of pleurisy the fluid 
only partly fills the thorax. On account of the small size of the 
thorax in infants, it is impossible to determine the change of level 
of the fluid by changing the position of the patient. 

The resonant note over the lung apex in front should, in the pres- 
ence of dulness behind and flatness below, always arouse suspicion of 
fluid, for in these eases the lung seems to be compressed upward, 
forward, and inward, thus causing the vesiculotympanitic note in 
front and above. 

The chest is partly filled with fluid, as is shown in Figs. 117 and 
118. I have quite frequently found this condition in infants and 
children who have constantly lain on the back, and in whom adhe- 
sion.- seem to have kept a layer of fluid in the position shown in the 
figure. It will be assumed for illustration, that the right side is 
affected : 

On inspection, fulness of the intercostal spaces on that side 
may be detected ; the movement of the thorax is labored, and the 
intercostal spaces may be drawn inward on inspiration. 

Palpation. — Vocal fremitus due to the lung's being in contact with 
the chest-wall may be present over the anterior aspect of the chest. 
Posteriorly, the fremitus will be entirely absent. 

Percussion. — Anteriorly, the note may be vesiculotympanitic; 
posteriorly, there i- complete dulnese over the whole chest, which is 

27 



418 



DISEASES OF THE RESPIRATORY TRACT. 



more marked below. There is rarely the flatness obtained when the 
chest is full or half full of fluid. There is also resistance to the 
percussing finger. 

By percussing firmly the note of the lung beneath will invariably 
be elicited ; breathing-sounds and voice-sounds will be heard as 
normal or distant. 

Pleuritic crepitations may be heard over the whole aifected side ; 
there is no displacement of the liver or heart on the left side. 

Diagnosis of fluid before exploratory puncture must rest on the 
complete or partial absence of fremitus behind, and complete dulness 



Fig. 117. 



Fig. 118. 





Fluid in a thin layer posteriorly in the pleura. 



or flatness. The quantity of fluid is small ; there is less resistance 
to percussion than when it is large. 

(B.) The Chest Full of Fluid (Bight Side). — On inspection, the 
objective signs of intense or moderate dyspnoea are found : The 
chest on the affected side is immobile ; the intercostal spaces are re- 
tracted with each inspiration ; the affected side bulges visibly. 

Palpation. — Vocal fremitus is lost over the whole side in front 
and behind. In rare cases a little fremitus is felt. 

Percussion . — Ordinary and firm percussion give a flat note over 
the whole chest in front and behind ; the resistance to the percussing 
finger is wooden. In front, flatness may be present over the 
apex of the lung (Fig. 119). In some cases in children a 
sound over the apex of the lung, which resembles the cracked- 



PLEURISY WITH EFFUSIOX AXD EMPYEMA. 



419 



pot sound over cavities in adults, may be obtained. It may be due 
to lung compression. In other cases the resonance in front, over 
the lung of the affected side is vesiculotympanitic, owing to the 
pushing upward and forward of the lung and to its distention. 

Displacement of the Pleural Fold underneath the Sternum. — A 
very important aid in the diagnosis of fluid in either side of the 



Fig. lli». 



Fig. 120. 





Pleura] cavity full of fluid. Flatness 
anteriorly and posteriorly. 



Pleural cavity filled with fluid. Lung 
displaced upward and forward. Resonance 
anteriorly over the apex, either vesiculo- 
tympanitic or of the cracked-pot quality. 



chest is the displacement of the line of the reflection of the pleura 
in front. Normally the pleurae of both sides meet underneath the 
Bternom in the median line. Above, at about the level of the second 
rib, they depart gradually from each other. If there is a large amount 
of fluid in the right (hot. the pleural fold of that side becomes 
distended and displaced to the left, and may be marked out above 
the heart by dulness to the left of the midsternum. If the left 
chest is full of fluid, the left pleural fold is displaced to the right 
and there is distinct dulness or flatness above, to the right of the 
midsternum (Fig. 121). 

Auscultation. — Auscultatory signs in infant- and children are 
most puzzling when the chesl is full of fluid, and little diagnostic 
value can be attached to them in some cases. The chesl may be 
full of fluid while the breathing and the voice may be heard a- on 



420 



DISEASES OF THE RESPIRATORY TRACT. 



the unaffected side, aud pleuritic crepitant rales or crepitations may 
be beard over tbe whole chest behind. In other cases, the breathing 
may be indistinct and distant, and in the lower part of the chest 
lost entirely. The voice may be bronchophonic in certain localities ; 
it may be of this quality over the whole diseased side of the chest 
behind, or the tubular sound may be conducted to the healthy side. 
The voice may be normal above and heard faintly below, toward the 
base of the lung. 

Diagnosis before exploratory puncture rests mainly on (a) com- 
plete absence of fremitus ; (6) absolute flatness on percussion with 

Fig. 121. 







'x\ '-"'; 




V 




/ 




f; 


) I 


ft. 


\ 


% 

1. 





Displacement of the left pleural fold in effusion (empyema) into the left pleural cavity 
flatness to the right of the midsternum as indicated. Child, two years of age. 



resistance to percussion ; (c) bronchial voice and breathing over the 
whole chest behind ; (c?) hyperresonance over the apex, and displace- 
ment of viscera, and of the pleural fold in front. 

Displacement of Viscera. — Liver. — In infants and young 
children the presence of fluid may be indicated by displacement of 
the liver downward on the right side. I have been able to verify the 
displacement in cases in which large amounts of fluid were present. 
In infants, the liver is so large and the projection below the border of 



PLEURISY WITH EFFUSION AXD EMPYEMA. 421 

the ribs so undetermined; that it is difficult to estimate the exact amount 
of displacement. The chest is so easily dilated that an ordinary 
amount of fluid accommodates itself without markedly displacing 
so heavy an organ as the liver. In children I have been able to 
make out a displacement oi' the liver downward before the evacua- 
tion of large quantities oi' fluid. Displacement is of confirmatory 
value in diagnosis. 

Heart. — The heart-apex may be displaced toward the median 
line by fluid in the left pleural cavity. In older children also 
when the amount of fluid is large the apex is displaced and lies 
beneath the lower part of the sternum. A small amount of fluid 
will not always cause displacement, but will find its way around the 
heart. 

Remarks upon the Diagnosis of Fluid in the Chest, with Excep- 
tional Signs. — It is not always easy, even for the expert, to decide 
without puncture as to the presence or absence of fluid in the chest 
of infants and young children. The following signs will be of 
service at the bedside. 

Duration of Illness. — If an infant or child has been ill for 
two weeks or more with signs of pneumonia during the early part 
of the disease, the physician should be watchful in the presence 
of the following conditions : If the temperature does not fall, but 
though remitting still continues ; if the signs of consolidation of a 
small or large area give place to dulness or flatness over a whole 
side behind, with bronchophony over the whole side — for if the con- 
dition of the infant is tolerably good, it is evident that such bron- 
chophony may not be due to the total consolidation of the whole 
lung ; if there is displacement of viscera, chiefly of the liver or the 
heart ; if there is drawing inward of the intercostal spaces during 
inspiration, with real immobility and bulging of a side and dulness 
or flatness and loss of fremitus. 

Fluid is very rarely encapsulated in a small area behind, about 
the midregion of the chest. Such areas are usually areas of per- 
sistent bronchopneumonia. In most cases, there is localized dul- 
ness, above and below which there is vesiculotympanic resonance, 
normal pulmonary resonance or exaggerated resonance. There is 
distinct respiratory movement of the affected side. On the other 
hand, a collection of fluid between the lobes of the lungs (inter- 
lobar) may give a localized flatness and all the auscultatory signs, 
such as bronchial voice and breathing, of a local collection of 
fluid. 

There are certain localities in which the diagnosis of fluid must 
be made with reserve : 

". In a case on which I operated, fluid was found posteriorly 
over the situation of the upper lobe of the right lung. The fluid 
was completely -hut off from the rot of the pleural cavity by a 



422 DISEASES OF THE RESPIRATORY TRACT. 

membrane stretching from the thoracic wall to the interlobar fissure 
of the lung. Post-mortem showed the case to be tuberculous, the 
lung on the affected side being the seat of persistent tuberculous 
bronchopneumonia. I have seen similar cases which were meta- 
pneumonic. 

6. Fluid over the upper lobe in front only, is rare. I have seen 
one case, but no operation or verification was permitted. 

c. Fluid over the lower lobe of the lung, in front on the right or 
left side without corresponding signs behind, is uncommon. 

d. Circumscribed collections of fluid behind over the middle 
region of the lung or toward or in the axillary line are exceedingly 
uncommon. 

e. In the chapter on the physical signs of pericarditis, it will 
be shown how a pleurisy or empyema on the left side may be mis- 
taken for pericarditic effusion. 

Physical signs having led the physician to suspect fluid, the 
chest should be explored for two distinct reasons : to determine abso- 
lutely the presence of fluid, and to ascertain whether it is serous or 
purulent. 

Diagnostic Exploratory Puncture of the Chest. — The instru- 
ments necessary are an exploring needle, a millimetre in calibre, 
and a large barreled aspirating syringe. The needle should not be 
too short, else it may snap off in the chest. The needle and 
syringe are boiled for a few moments before being used. The 
patient is held in the arms of the nurse or mother, so that the 
posterior aspect of the chest may be exposed. Older children may 
sit on a table. The chest is scrubbed with soap and water, washed 
off with ether, then with alcohol, and finally with a solution of 
sublimate (1 : 2000). The arms of the infant or child are firmly 
held and the chest steadied in such a manner that should the 
patient move suddenly the needle will not break in the chest 
(Plate XVII.). 

Introduction of the Needle. — The chest is again percussed 
and the needle introduced into the intercostal space in which per- 
cussion elicits the most marked dulness or flatness. This rule should 
be invariably followed ; the needle should not be introduced into 
any particular intercostal space. On the right side the physician 
should avoid putting in the needle too low clown (liver) ; on the left 
side he should avoid introducing it too deeply for fear of wounding 
a large vessel at the root of the lung. The needle should not be 
entered too near the vertebral column. The needle having been 
introduced one or two centimetres, the piston is drawn and held thus 
a few seconds. Sometimes the fluid is thick and does not flow freely 
into the syringe. The syringe should not be introduced and then 
withdrawn and pointed up and down in various directions in quest 
of fluid, for fear that the struggles of the patient, even if he is firmly 



PLATE XVII. 




>*- 



Showing the Method of Making an Exploratory Punctur 
for Fluid in the Pleural Cavity in an Infant. 






PERFORATING EMPYEMA. 423 

held, will cause puncture of the lung and bloodvessels. The 
needle should be withdrawn as rapidly as it was introduced and the 
whole operation completed in less than a minute. The external 
wound is covered with a small strip of iodoform gauze held in 
place with rubber plaster. The needle while in the chest should 
be held loosely. If it is held firmly, any sudden movement of 
the patient will cause it to break off in the chest. The needle 
should not be introduced too deeply for fear that it may enter a 
dilated bronchus and withdraw purulent secretion which may be 
mistaken for empyema, or that it may wound the lung and cause 
hemorrhage. 

Perforating Empyema. 

An empyema may perforate externally. In that case there will 
be an extensive infiltration of the tissues external to the ribs on the 
affected side, resembling a large phlegmon, and the signs of fluid will 
persist. If the perforation occurs on the left side, the movements 
of the heart are likely to be conducted to the external swelling, and 
there is then what has been called pulsating empyema. The em- 
pyema may perforate through the lung, and the signs will then vary 
with the length of time during which the perforation has existed. 
It is customary for writers to repeat one another in recounting the 
physical signs of pneumothorax in a chest in which fluid (pleurisy 
or empyema) is present. In infants or very young children the 
following classical signs of pyopneumothorax observed in adults are 
not commonly found : amphoric breathing, amphoric voice, metal- 
lic tinkle, and suceussion-sound-. My eases were in children under 
two years of age. The perforation in the lung must have been too 
small or too valvular to permit of the entrance of much air into the 
pleural cavity. These eases at first showed all the signs of the con- 
dition which was proved, on introducing the needle, to be empyema. 
Operation being refused, after a few weeks (three months after the 
beginning of the disease), the signs changed as follows : 

Periodic expectoration of large quantities of pus following 
coughing spells. 

Fremitu- diminished over the whole right side and almost lost 
below. 

Dulness over the whole side in front and behind, with tympani- 
tic note on deep percu— ion only. Voice normal ; breathing 
normal — at least not varying from that on the healthy side. In 
the intervals of expectoration, there were in some eases bronchial 
voice and breathing. 

No succussion-eounds, no tinkling, no amphoric signs. The 
classical signs seen in adult- are met in children above five years 
of age. 



424 



DISEASES OF THE RESPIRATORY TRACT. 



Course and Termination. — Pleurisy with effusion and empyema 
have been considered together, because, in infants and children under 
two years of age, the effusion in the chest may at first be serous, but 
subsequently change into purulent exudate. A serous effusion may 
be followed by a purulent one ; it may remain serous and be absorbed 
as such. Thus it is best, especially in infants, to introduce an 
exploring-needle into the chest to determine the nature of the fluid 
as soon as its presence is suspected. In older children also, this may 
be done at the outset. If a clear fluid is at first obtained and the 
symptoms do not retrograde within a short time, the needle should 
be again introduced to determine whether the fluid has remained 
serous. It is frequently found to be purulent although no infection 
has occurred as a result of the first puncture. With ordinary cleanli- 
ness, the possibility of infecting a serous effusion in the chest and 
thereby causing it to become purulent is very slight. Purulent 
effusion appearing after the first exploratory puncture has shown the 
effusion to be serous, may be due to two causes : either to continu- 
ance of the pleuritic inflammation, or to the fact that if the infant 
or child has lain quietly in bed the purulent elements of the effusion 
have gravitated to the lower portion of the chest, leaving a clear 
serum above at the level of the puncture. 



Fig. 122. 



104 
103' 

1 102 

IE 

I 

d! 

§ 100' 



m 



« 



u 



m 



Empyema 



left pleura, followed thirteen days after operation by bronchopneumonia at the 
apex of the right lung. Male child, twenty months of age. Recovery. 



The prognosis of pleurisy with effusion and of empyema in in- 
fants and children is good. If treated in the proper manner, it is not 
more serious than the original causal affection. In private practice, 
the patient being under constant supervision of the physician, the 
outlook is very good. An effusion can be discovered early and the 
patient relieved. In hospital practice the results are still good if 



PLEURISY WITH EFFUSIOX AND EMPYEMA. 425 

the eases are simple and come under treatment before systemic in- 
fection has taken place. In my service of 120 cases of all kinds, 
there were 20 death-, 4 of which occurred from one to live days 
after operation. Sepsis had been present before operation and caused 
the fatal is>ue. The septic cases therefore give an unfavorable prog- 
nosis, as do also those of a tuberculous nature. In the latter, as in 
other forms of tuberculosis in children, the outlook is better than in 
the adult and recoveries are not infrequent. 

Of the 20 cases of death after operation for empyema, broncho- 
pneumonia either persistent or recurrent caused the fatal issue in 11, 
genera] sepsis in 2, marasmus and ulcer of the duodenum in 1, and 
cerebral embolism in 2. A complicating pericarditis of a suppurative 
nature may cause death. It is not always possible to diagnose this 
condition during life. The complication most to be feared in 
empyema is a bronchopneumonia involving either lung. In many 
cases the bronchopneumonia is present at the time of operation, or 
it may come on a week or two afterward during apparent conva- 
lescence. 

The prognosis of tuberculous empyema is not so unfavorable in 
children as in the adult. In the former, empyema of a tuberculous 
nature, like other forms of tuberculosis, may with skilful management 
make an apparent recovery, though with marked deformities of the 
chest-wall. In this form of empyema the pleura is thickened, bind- 
ing down the lung and thus preventing expansion. Extensive rib 
resections thus become necessary in order to close up the suppurating 
cavity left by the unexpanded lung. 

Treatment. — If on exploratory puncture a serous exudate which 
only partly fills the pleural cavity is found, the expectant plan is 
followed. The bowels are kept open with an enema or a saline 
cathartic is administered daily. For this purpose a saline enema, 
or in older children a teaspoonful of Carlsbad salts in warm water 
mixed with milk, is efficient. Local vesication is not needed nor is 
it advisable. The effusion is absorbed if the patients are kept 
quiet and the diet is easily assimilable. Citrate of potassium in 
grain v (0.3) doses every three hours may be given to older chil- 
dren. If the fluid increases in quantity, fills up the chest, causes 
dy-pnoea or pressure symptoms, and is serous in character, the chest 
should be aspirated. The best form of aspirator for the practitioner 
is the Potain. The patient is aspirated in the sitting posture. The 
ehest-wall having been cleansed, the needle is introduced in the 
posterior axillary line toward the lower third of the chest cavity. It 
i- not withdrawn until the flow has ceased or the lung can be felt 
against the needle in the pleural cavity. Afl SOOD as this occurs the 
needle is withdrawn and the puncture opening covered with a piece 
of iodoformized L r anx<-. It sometimes happens that there are signs 
that the chest i- tilled with fluid and yet verv little flows into the 



426 DISEASES OF THE RESPIRATORY TRACT. 

instrument. In such cases the needle should be withdrawn and 
introduced into the chest-wall at another point. The coughing attack 
which occurs during aspiration will subside on the patient's taking 
the recumbent posture. If the chest is quite full of fluid, it is well 
not to empty it entirely. Sometimes alarming syncope with other 
signs of cardiac weakness, such as cyanosis, has supervened. If a 
limited quantity of fluid is removed, the absorption of the rest will 
follow rapidly. 

A daily saline cathartic is given ; the patient is kept quiet and 
allowed a nutritious and easily assimilable diet. The administra- 
tion of salicylate of sodium may hasten absorption, especially in 
cases in which there is a rheumatic history. If there is pain or a 
harassing cough, small doses of codeine should be given. 

Empyema. — When the presence of pus in the chest is once estab- 
lished, it is imperative that it be evacuated with the least possible 
delay. In infants and children it is not advisable to temporize by 
first performing aspiration. Retention of even a limited quantity 
of purulent exudate in the pleural cavity not only leads to emacia- 
tion and physical weakness as a result of continued fever, but general 
sepsis may also result. Aspiration is not efficient, and is to-day 
practically abandoned as a mode of treatment. The physician may 
either incise the intercostal space or resect a rib to obtain drainage. 

Simple incision in the intercostal space is efficient in many cases 
of empyema occurring in the first eighteen months of life. In these 
frail patients, excision of the rib has been sometimes accompanied 
by discouraging results. 

The greatest number of deaths after any operative procedure for 
the relief of empyema occur in children under the age of eighteen 
months. The strength of the patient should be supported as much as 
possible. A general anaesthetic is not necessary for patients under this 
age. I find that bronchitis and pneumonia very frequently result from 
the general use of anaesthetics in young patients. Local anaesthesia 
is all that is needed. Ethyl chloride in tubes is very efficient. The 
surface of the chest is carefully cleansed with soap and water, alco- 
hol, ether, and sublimate. An incision two inches long or there- 
abouts is made obliquely in the tissues over the intercostal space. 
The space in which a needle has been previously introduced and 
pus found is chosen. The exploring-needle is always introduced 
just before operation. Frequently, although pus has been with- 
drawn from the chest, at a second aspiration none can be found. 
The theory is that either there was a small localized collection of 
pus at the first point of aspiration, or that the needle entered a 
bronchus and withdrew secretion collected there. 

On the right side the incision should not be too low, else a tube 
cannot be retained in the chest on account of the high position of 
the diaphragm. The seventh or the eighth space in the posterior 



PLEURISY WITH EFFUSION AND EMPYEMA. 



427 



axillary line is the best location if pus is present at this point (Fig. 
123). On the left side, incisions should not be made too far for- 
ward, else the drainage-tube may impinge against the pericardium. 

The superficial tissues having been incised, the intercostal 
muscle is incised, the operator keeping as nearly as possible in the 
median line of the intercostal space and avoiding the lower border 
of the upper rib, vet not cutting too close to the lower rib. When 
the vicinity of the costal pleura is reached, a closed dressing-forceps 



Fig. 123. 




/f^tytt'S 



Empyema, site of incision in line with the angle of the scapula. Infant, twelve months 

of age. 



is introduced into the pleural cavity and opened to widen the 
puncture. A small drainage-tube or two small tubes are placed in the 
pleural cavity and prevented from falling into the pleural space by 
safety-pins passed through them at the distal ends. The pus is not 
evacuated at the time of operation. The sudden evacuation of fluid 
which has been retained in the chest for a long time is apt to cause 
untoward syncopal symptom-. Gibson has made the excellent sug- 
gestion that as soon as die pleura is oj>ened the drainage-tube should 



428 



DISEASES OF THE RESPIRATORY TRACT. 



be quickly introduced into the chest, the gauze dressings applied, 
and the pus allowed to escape gradually into the dressings. The 
dressings consist of a pad of gauze around the tubes, covered by 
a dry sterilized gauze dressing which is renewed every day. The 
chest should not be irrigated. No instrument should be introduced 
into the chest cavity to loosen adhesions. The whole operation is 
extremely simple, and should not occupy more than a few minutes. 
Children under five years, and even older ones may be treated by this 
method. In the older subjects, however, the chest- wall is not so 
resilient ; there are adhesions, and if they are numerous and clots are 
abundant in the exudate a subsequent excision of the rib may be 
necessary. On the other hand, the main object of the practitioner 
in these cases is to evacuate the mass of pus, and incision will 

Fig. 124. 




Bisection of rib for empyema on the right side. Shows the resulting deformity. Five weeks 
after operation. Child, four years of age. 



accomplish this quite as well as the other operation. If subse- 
quently, more drainage is needed, the patient will be stronger and 
better able to stand the more serious procedure. 

Incision is therefore the practitioner's operation even in older 
children, with whom anaesthesia must however be used. Chloro- 
form is the safest and most easily taken ; very little need be 



PLEURISY WITH EFFUSION AND EMPYEMA. 



429 



used. As soon as the skin Incision has been made, anaesthesia 
should be suspended. 

I perform excision of the rib in all the cases in children above 
eighteen months, unless there is a contraindication. Severe pneu- 
monia, high fever, cardiac weakness, acute pericarditis or endo- 
carditis, as complications, are contraindications. In such cases 
incision alone is performed. I excise the rib in the usual way, taking 
two or three centimetres of rib subperiosteal^ and incising in the 
midline of the posterior layer of periosteum to enter the pleural 
cavity. The linger is not inserted into the pleura to loosen adhe- 
sions. Alter the pleura is opened, double drainage-tubes are intro- 
duced by Gibson's method, as in the operation of simple incision. 

Sinus. — After incision or resection of the rib, a suppurating sinus 
may remain for months. If a probe introduced into a sinus of this 
kind impinges against callus or denuded bone, a so-called sec- 
ondary operation is necessary to take out the denuded rib or callus. 
This involves a difficult surgical procedure, which it is not necessary 
to describe here. A sinus of this form will not close until the bone 
is removed. Temporizing only subjects the patient to the dangers 
of prolonged suppuration (amyloid degeneration). 

Adhesions binding down the Lung. — There is another class of 
cases in which a large amount of fibrin has been thrown out on the 



Fig. 125. 




James' apparatus for expanding the lungs in empyema. 

visceral pulmonary pleura. The lung J s thus cramped bv an en- 
velope of thickened pleura and cannot expand. -A large suppu- 
rating cavity or a suppurating sinus i- left between the pulmonary 
and costal pleura. This cavity must be made to close. In such 
cases the patients are allowed to be up and about. They are taught 
to blow colored fluids from one bottle to another in the wav de- 
scribed by James, of New York | Fig. 126). Two bottles of equal 



430 DISEASES OF THE RESPIRATORY TRACT. 

size, each half filled with the fluid, are used. In simple cases this 
method is very efficient ; in others it is of no avail. The operation 
of taking out two or more ribs with the intervening pleura must 
then be performed. In other cases a more extensive operation — 
the so-called Estlander, in which large pieces of several ribs are 
excised with the intervening costal pleura — is necessary. If the 
lung is firmly bound down by a coating of fibrin, the chest-wall 
must be opened by reflecting a flap of several ribs and the soft 
parts. The pleura is peeled off the lung according to the method 
of Delorme. The lung expands, the costal flap is sewn back in its 
place, and the chest sinus is in time closed as a natural consequence. 

The question of irrigating the pleural cavity in the treatment of 
empyema after operation has been much discussed. As a rule if 
the temperature drops after operation and remains low, and the dis- 
charge is not fetid, no irrigation is indicated. If, however, there 
are rises of temperature after operation, with a profuse or fetid dis- 
charge, the chest should be irrigated once daily with normal salt 
solution. 

Bilateral Empyema. — The treatment of bilateral empyema will 
tax the judgment of the physician. One side, preferably the left 
in order to relieve the heart, is first operated on by incision or rib 
exsection ; the other side is aspirated, and again aspirated if the 
fluid or pus accumulates. After a week adhesions will have formed 
on the operated side, and the strength of the patient will warrant 
interference on the opposite side. When this is accomplished, the 
opening on the operated side must be closed by some device, such as 
a pad of gauze on which is placed rubber tissue covering, and the 
second side may be operated on by rib exsection or incision. 

I have followed this method in two cases without serious acci- 
dent. The interval of a few days between the operations is 
sufficient to allow adhesions to form on the operated side to such an 
extent that, when the second side is opened, the lung of the side first 
operated on does not collapse. If the sides are operated on simulta- 
neously, the consequent partial collapse of both lungs causes marked 
symptoms of asphyxia. 

Hemorrhagic Pleurisy. 

Simple hemorrhagic pleurisy is not uncommon. It is seen in 
pleurisy following simple pneumonia, influenza, the exanthemata, 
and in infants or children in whom there is a tendency to scor- 
butus. Cases which appear to be rheumatic have been published 
(Starck). The hemorrhagic form of pleurisy with effusion may occur 
in very young infants (Lewin, eleven months) or in young children. I 
have met a number of cases in children who subsequently made a 
complete recovery, and in whom I could find no tuberculous ten- 



SUBPHRENIC ABSCESS. 431 

dencies. The prognosis in this form of pleurisy is therefore much 
better iu children than in adults. In the latter, a hemorrhagic pleurisy 
is frequently indicative of a tuberculous factor in the etiology. 

Hemorrhagic Empyema. 

Hemorrhagic empyema is also not uncommon in infants and chil- 
dren. During the past year I have met four cases in which there was 
a hemorrhagic exudate. Iu one case the child was pale, though not 
emaciated. There may have been a scorbutic element. In another 
case, in a boy, no such etiology was indicated. In a third case, in a 
girl, the child was much reduced in health. In three cases the hemor- 
rhagic discharge persisted for days after the chest was opened and 
streptococci were found in the exudate. In one case the discharging 
pus was for weeks tinged with blood. In none of the cases were 
tubercle bacilli found in the pleuritic exudate. Three of the cases 
made a very good recovery. In these cases also I am inclined to 
believe that tuberculosis is not always an etiological factor. 



SUBPHRENIC ABSCESS OR PYOPNEUMOTHORAX 
SUBPHRENICUS. 

The positive diagnosis of subphrenic abscess should be made 
with reserve, because no pathognomonic symptom or physical sign 
of the disease is known. It is a very valuable fact that in 50 
per cent, of the cases thus far recorded, the abscesses have contained 
gas or air. The condition is rare (Maydl) in adults and more so 
in infants and children. The abscess is situated beneath the dia- 
phragm, and between that organ and the liver. It pushes the dia- 
phragm upward, and may thus encroach on the pleural space and simu- 
late a real pyopneumothorax. A tumor in the lower port of the 
thorax, which may give tympanitic resonance or tympanitic dulness 
from the second, third, or fourth rib downward, is thus caused. This 
re-onance may even include the liver, which is displaced downward. 
Over the region of tympanitic resonance, (■specially posteriorly, (he 
normal vesicular breathing i- absent on expiration and present over 
the tumor on deep inspiration. It is a peculiarity of the condition 
that there may be amphoric breathing and metallic tinkle over the 
tumor, while anteriorly ju-t above it from the second to the fourth 
rib, there is a sharp transition and normal breathing is heard. Behind, 
however, on deep inspiration, even over the region <>f* tympanitic 
resonance, normal breathing may be heard over the lower part of the 
chest. Over the situation of the abscess the metallic tinkle and suc- 
cussion-sounds may also be heard. A- has been stated, the liver 
may be displaced downward, crepitations are heard anteriorly over 



432 DISEASES OF THE RESPIRATORY TRACT. 

the liver (perihepatitis), or it may be impossible on account of intes- 
tinal conditions to make out the lower border of the liver. I have 
seen a subphrenic abscess on the left side displace the left lobe of the 
liver and the spleen downward. The heart is not displaced inward 
if the abscess is on the left side, but if displaced at all, is so in an 
upward direction. The lower thorax region may show no abnor- 
malities to inspection, while the upper abdominal region may be 
normal, painful to pressure, or slightly oedematous. 

Diagnosis and Treatment. — Exploratory puncture is resorted 
to in all of these cases. Diagnosis will be aided if the fluid obtained 
contains, in addition to pus, elements which denote the origin of 
the abscess, such as food particles, feces, histological debris or pig- 
ment from the liver. In many cases the liver suffers from the 
vicinity of the abscess. 

The treatment is surgical. 

Leading Authorities Referred to in Chapter VI. 

Bonnard-Fovre : La temperature dans la pneumonie. Paris, 1898. 

Booker : Johns Hopkins Hospital Keport, vi., 1896. 

Bowditch: Medical News, 1889. 

Cestan : La Therapeutique des Empyemes. Paris, 1898. 

Czerny and Mow : Jahrb. f. Kinderheilk., Bd. xxxviii. 

Finkler, D. : Die Acuten Lungen Entziindungen, etc., 1891. 

Fischl, R. : Volkmann's Vortrage, No. 220. 

Holt, L. E. : "Pneumonia in Young Children," Medical Eecord, 1885. 

Jiirgensen : Croupose Pneumonie, 1883. 

Netter: Soc. med. des Hopit., 1889-91. 

Neumann: Jahrb. f. Kinderheilk., Bd. xxx. 

Pott: "Pneumonie in Kindesalter," Bib. d. ges. med. Wissen., Bd. iii., 1898. 

Pratt, I. H. : "Histology of Acute Lobar Pneumonia," Johns Hopkins Hos- 
pital Report, vol. ix. 

Prudden and Northrup: "Studies in Pneumonia," etc., American Journal 
Medical Sciences, 1889. 

Spiegelberg, I. H. : "Lungen Entzundung u Magendarmkr.," Archiv f. Kinder- 
heilk., Bd. xxvii. 

Steffen, A. : Klinik der Kinderk., etc., to 1895. 

Stengel, A., and C. Y. White: "Blood in Infancv and Childhood," Arch, of 
Ped., April and May, 1901. 

Terrier and Reymond : Chirurgie du Coeur, Paris, 1898. 



CHAPTER VII. 

DISEASES OF THE HEART AND PERICARDIUM. 

HEART. 

The height of the heart and of the great vessels in children does 
not after the third year materially differ from that in the adult. 
The ratio of the transverse to the sagittal diameter of the chest 
in newborn infants is 2 to 1, while in adults it is 3 to 1. This 
fact should not be forgotten in estimating the size of the heart in 
infants and children. What in an adult might appear to be a large 
heart, is normal in an infant or a young child. 

Position. — In the first year of life the long axis of the heart is 
more horizontal than in later childhood or in adult life (Rauchfuss). 
At the third year, the position of the heart is practically that found 
in the adult (Dwight). 

As the child becomes older the heart assumes more nearly the 
vertical position, and in older children the apex-beat may be found 
0.75 to 1 centimetre within the mammilla ry line. The situation of 
the mammillary line is variable in young children ; the nipple is 
over the fourth rib, but further removed from the midsternal line 
than in older children on account of the greater transverse as com- 
pared to the longitudinal diameter of the thorax. In older children 
the heart areas closely resemble those in the adult. In infants and 
young children there are certain variations from the adult condition 
which should be borne in mind. 

Size. — The heart is relatively larger in the infant than in the adult, 
having 0.89 per cent, of the body weight in the newborn infant, while 
in the adult it has only 0.52 per cent. ( Yierordt). 

Apex-beat. — The apex-beat in the newborn infant may be felt 
higher than in the adult. On account of the greater breadth of 
heart as compared with that of the chest the apex is external to the 
mammillary line. Steffen says, that normally the apex-beal may be 
found 1 centimetre external to the mammillary line <>?• in the mam- 
millary line, or internal to the mammillary line The apex -beat in 
infants and children i- in the fifth space. 

Inspection. — Inspection -how- in some cases an undnlatory move- 
ment over the whole cardiac region. This is normal as long as it is 
confined to the left of the sternum, but an undulatory movement to 
the right of the sternum i- probably indicative of dilatation of 



434 DISEASES OF THE HEART AND PERICARDIUM. 

the right ventricle with or without hypertrophy. In rachitis the 
cardiac region is sometimes unduly prominent. This condition 
must be distinguished from the more pronounced fulness in the 
praecordium occurring in cases of hypertrophy or of pericardial 
effusion. The apex-beat should not be mistaken for an apparent 
apex-beat which is sometimes seen in young children in whom 
the intercostal space to the left of the large cardiac dulness is 
raised with each pulsation of the apex. Percussion in these cases 
will show the apex to be situated elsewhere to the left and 
downward. In some cases the apex, instead of pushing the in- 
tercostal space forward, draws it distinctly inward. This is in part 
due to adhesions between the heart, pericardium, and parts external 
to the pericardium. When children are struggling, the systolic im- 
pulse of the heart is seen to be communicated to both the carotid 
artery and the jugular vein, the vein getting its impulse from its 
proximity to the artery. The vein may be found to be collapsed 
and the artery to show an impulse on systole. 

Palpation. — The following points may be determined by palpa- 
tion with the tips of the fingers or full palm : 

1. Location of the apex-beat. 

2. Sometimes the location of the left boundary of the heart. 

3. The force of the systole, hypertrophy or dilatation of the 
heart, especially if pulsation is evident to the right of the sternum. 

4. Transposition of the heart to the right. 

5. The closure of the valves of the pulmonary artery in the 
second or third space near the sternum (Steffen). 

6. Murmurs which cause friction (pericardial) or thrills (endo- 
cardial). 

7. Rhythm of the heart action. 

Auscultation. — In infancy the muscular quality of the first sound 
is not apparent. The heart-sounds have more the character of the 
tick-tack of a watch. The muscular character of the first sound 
fully develops toward the second year of life. All through infancy 
and childhood there is a natural accentuation of the second pul- 
monic sound. Too much importance should not be attached to 
the accentuation even if it is marked. 

Percussion. — The percussion of the heart has been the subject 
of much refinement of methods, which only tends to confuse a simple 
matter. The following method will be found suitable for most 
clinical purposes : 

The lines of demarcation are the midsternal line and a parallel 
line running through the left nipple. All reckonings as to the 
limits of cardiac dulness may be safely made from these lines, and 
such figures will be understood by all physicians. The right border 
of the sternum is not a good line to reckon from, since the width 
of the sternum varies. The recumbent posture is preferable in 



I it: ART. 



435 



infants ; both the recumbent and upright positions are suitable in 
older children. 

Method of Locating the Line of Dulness of the Left Ventricle. — To 
locate the external boundary of the ventricle, we begin to percuss in 
the lines parallel with the second, third, fourth, and fifth ribs toward 
the heart, from the axillary line or the anterior axillary line. To 
percuss from the midsternal line outward does not in children give 
as good result-. 




Form of the normal relative cardiac dulness in a child two and one-half years of age. 



To locate the external border of the right ventricle, we percuss 
along the fourth rib or fourth spare toward the sternum from the 
right mammillary line. In young infants a portion of the right 
auricle and ventricle will be found as high a- the junction of the 
second riband the sternum (Symington), but it i- an ultra-refine- 
ment of percussion t<> try to make out the projection of this part of 
the right auricle t<> the right of the sternum. It is found, anatom- 
ically, that the curve of the auricle to the right of the sternum 
begins at the third space, and i- most marked behind the fourth 

coital cartilage. It Is sufficient for clinical purposes to make 



436 DISEASES OF THE HEART AND PERICARDIUM. 

out this most projecting part of the heart to the right of and 
behind the sternum. 

The apex of the heart is generally made out by percussing along 
the fifth rib or fifth space from the antero- lateral axillary line toward 
the midsternal line. The external boundary of the left ventricle is 
in children slightly outside the apex-beat. The area of cardiac 
dulness which is absolute and which is uncovered by lung can best 
be made out by percussing from above downward over the cardiac 
area. In children or infants this area cannot be marked out as 
definitely as in the adult. The younger the child or infant, the 
greater the difficulty. In infants and children interest centres 
rather in the apparent size of the heart (relative dulness) than in the 
area uncovered by lung. 

The dulness extends to the right and left of the midsternal line, 
at a level with the fourth rib, as is indicated by the following figures 
compiled from Steffen's tables : 

Infants under one year right v. 4 to 6.5 cm. to right. 

left v. 3.5 to 6.25 cm. to left. 
Children one to two years right v. 4 to 6.5 cm. to right. 

left v. 4 to 7.25 cm. to left. 
Children two to three years right v. 4.5 to 7.5 cm. to right. 

left v. 4.5 to 6.5 cm. to left. 
Children five to six vears right v. 5.5 to 7.25 cm. to right. 

left v. 5 to 8.25 cm. to left. 
Children nine to ten years right v. 5.5 to 8.5 cm. to right. 

left v. 5.5 to 8.5 cm. to left. 

Enough has been selected to show that the actual size of the heart 
as obtained by percussion in infants and children is extremely vari- 
able, and that the physician must be guided by the relative size. 

The Pulse. — Rapidity. — The following table is given by Bednar : 

Beats per minute. 

Foetus 108 to 160 

First two minutes of life 72 to 94 

Fourth minute of life 140 to 208 

Eighth day to second month 96 to 130 

Second month to twenty-first month 96 to 120 

Second to fifth year 92 to 108 

Fifth to eighth year 84 to 100 

Eighth to twelfth year 76 to 96 

Eespirations in infants, 30 to 32. Pulse-respiration ratio, a to 4. 
In the second year, 1 to 5 or 6. Turning, crying, and coughing, 
raise the pulse fifteen to thirty beats per minute. During sleep the 
pulse falls fifteen to twenty beats. After the third month, the 
pulse is more rapid in girls than in boys. 

The Rhythm. — (a) In infants the pulse is normally arhythmic 
or irregular both in regard to time intervals and in relation to what 
is known as the respiration curve. 



CONGENITAL HEART DISEASE. 437 

(b) Dicrotism is a normal characteristic of the pulse in infancy 
and childhood. 

The irregularity of the pulse is in some cases not very marked, 
in others becomes more apparent under the influence of undue 
excitement. Dicrotism although very evident and due to the great 
cardiac elasticity in children (Landois) is never so marked as it is 
found to be in children who are the subjects of cardiac disease, per- 
tussis (heart strain), or acute infection (typhoid fever). 



CONGENITAL HEART DISEASE. 

Congenital heart disease may he suspected from certain physical 
signs which occur in that condition and are in a sense characteristic 
of it. These are cyanosis, changes in the area of cardiac dul- 
ness, and the presence of characteristic murmurs. 

Cyanosis. — The cyanosis which is characteristic of congenital 
heart disease does not occur in any of the acquired cardiac lesions. 
It is most common in the congenital forms of pulmonary stenosis of 
the artery, conus, or ostium. On the other hand, it may be absent 
in marked congenital disease, as in deficient ventricular septum and 
open ductus arteriosus. In the latter disease it may appear late in 
the condition, only at intervals, or not at all. It may be absent at 
birth and appear in infancy or childhood. 

Cardiac Dilatation and Hypertrophy. — The presence of a 
murmur of congenital origin does not necessarily indicate change 
in the area of cardiac dulness. In fact, a normal cardiac area is 
sometimes evidence of the congenital character of a murmur. 
Hypertrophy of the left ventricle should be present with hyper- 
trophy of the right ventricle, and a murmur to indicate open 
ductus arteriosus. Dilatation of the right ventricle is of value 
when present with a murmur indicating stenosis at the pulmo- 
nary valve. On the other hand, marked congenital defects may 
exist without any change in the size of the ventricle. Moreover, 
if the cardiac area is enlarged and the apex impulse weak, con- 
genital disease may he suspected. The weak apex impulse indicates 
dilatation. 

Murmurs. — The murmur most characteristic of congenital heart 
disease is a systolic murmur at the situation of the space between 
the second and third costal cartilage to the left of the sternum, and 
not conducted into the arteries of the neck. It is only when there 
are complicated defect- that murmurs are conducted into the carotids 
(open ductus arteriosus). 

Foetal endocarditis affecting the tricuspid or mitral valves i> 
rare, and therefore murmur- of congenital origin are rare at these 
val\ ■■ 



438 DISEASES OF THE HEART AND PERICARDIUM. 

Diastolic murmurs are, so far as congenital lesions are concerned, 
of theoretical interest only. 

Systolic murmurs, such as those heard in cases of defects of 
the ventricular septum, and which cannot be attributed to valvular 
disease, occur at the pulmonic valves. In these cases the murmur has 
no point of greatest intensity, but is heard not only at the valve, but 
also over the whole prsecordium. The valvular sounds are dis- 
tinct. The most marked congenital defects or disease of the heart 
may exist without any murmur or other physical signs during life. 

In simple pulmonary stenosis, the second pulmonic sound is 
weak ; in cases complicated with open ductus arteriosus and hyper- 
trophy of the ventricles, it is accentuated ; in cases of pulmo- 
nary stenosis and deficient ventricular septum, it is either weak or 
very low. 

The positive diagnosis of the exact lesion in congenital heart 
disease is in many cases impossible. The reason for this is easily 
found in the fact that if the patient lives longer than the first 
year, the lesion is rarely simple, but occurs with other congenital 
defects in the heart. Another cause is the rarity of autopsies on 
uncomplicated cases which have been carefully studied during life. 
Lastly, in complex cases, even if the diagnosis has been confirmed 
at autopsy, it is impossible to say to what degree the- lesion diagnosed 
and the other complicating conditions found at autopsy have been 
the cause of the signs and symptoms found during life. The physi- 
cal signs of congenital heart disease vary as the lesion is a simple 
one or is combined with other congenital defects. The following 
classification of congenital heart disease of developmental or foetal 
endocarditic origin will be found useful in clinical work : 

1. Septum Defects. — Auricular (foramen ovale) ; ventricular. 

2. Pulmonary Artery. — Stenosis of the conus, trunk, or ostium : 
(a) simple cases (before the end of the first year of life) ; (b) com- 
plicated cases with open foramen ovale or ductus arteriosus, defect 
of the ventricular septum, or transposition of the great vessels. 

3. Aortic Valve Stenosis or General Contraction of the Aortic Sys- 
tem. — The first may be due to developmental defect or to foetal endo- 
carditis ; the second, to developmental defect. All aortic conditions 
anomalous in character have, so far as is known, not been posi- 
tively diagnosed during childhood. 

4. Valvular anomalies of the semilunar valves, due to foetal 
endocarditis or developmental irregularities are of purely scientific 
interest. 

5. Open Ductus Arteriosus or Botalli. — (a) Simple ; (b) combined 
with septum defects or pulmonary stenosis. 

6. Transposition of the Heart and Congenital Anomalies of the 
Pericardium (of purely scientific interest). 

From the above account, which I have modified for practical use 



STENOSIS OF THE PULMONARY ARTERY, ('ONUS, OR OSTIUM. 439 

from the classification of Vierordt, it will be seen that only the con- 
genital anomalies of the auricular ventricular septum, the pulmonary 

artery, and the ductus arteriosus Botalli are of interest to the clinician. 

Stenosis of the Pulmonary Artery, Conus, or Ostium. 

This is the most common of all congenital heart lesions. If 
found after the thirteenth month of life, it is in most cases combined 
with a congenital deficiency of the septum ventriculorum. Rauchfnss 
found a simple stenosis in only 10 per cent, of all the published 
cases. Most of the eases are due to foetal endocarditis. 




ngenital pulmonai «rith open ductus Botalli, as shown by a dull area in the 

Becond space above the base of the heart ; loud systolic murmur at the pulmonary orifia : 
clubbed till _ • r.il surface, symptoms of chronic bronchitis; dyspnoea 

on exertion. Boy, twelve yeai 

Physical Signs. — Simple stenosis of the artery, conus, or ostium, 
found only before the thirteenth month (Rokitansky). 

Cyanosis. — Early and congenital cyanosis with signs of venous 
c tasi<, such ;i- clubbed extremities of the fingers, even in young in- 



440 DISEASES OE THE HEART AND PERICARDIUM. 

fants. In cases which are met in later life, the clubbing of the 
extremities of the fingers and cyanosis of the finger-tips are marked. 

Murmur. — A systolic murmur heard with greatest intensity at the 
situation of the pulmonary valve to the left of the sternum, between 
the second and third costal cartilages, and not conducted into the 
carotids. A weakened second sound at the pulmonary valve ; dila- 
tation of the right ventricle. 

Simple stenosis is found in infants, but is rare. In most cases 
there are also present congenital defect of the ventricular septum, 
open ductus arteriosus, tricuspid changes, or the aorta arises from 
the right ventricle or both ventricles. The following facts should be 
kept in mind in the diagnosis of cases occurring after the thirteenth 
month of life : 

If the above signs are present with a weakened second pulmonic 
sound, there being absolutely no conduction of the murmur into the 
carotids, it may be assumed that there is a pulmonary stenosis with 
an open foramen ovale. 

Conduction of the murmur into the arteries of the neck, with a 
very distinct though not accentuated second pulmonic sound, points 
to the presence of a septum defect with a pulmonary stenosis. 

An accentuated second pulmonic sound with conduction of a 
murmur of a loud buzzing character into the subclavian and carotids, 
and a hypertrophy of the right and also of the left ventricle, will sup- 
port the theory of a pulmonary stenosis with a patency of the ductus 
arteriosus (Fig. 127) (Hochsinger). In these cases of open ductus 
arteriosus there is a thrill and a distinctly defined area of dulness in 
the second space to the left of the sternum above the base of the 
heart. This dulness is of great diagnostic import. It is due to the 
dilated great vessels at the base of the heart. 

As an exception to the above classification, may be mentioned the 
case of Sansom, in which cyanosis and extreme anaemia were pres- 
ent. In rare cases, the second pulmonary sound may be very low. 
The murmur may be conducted into the axilla, the right heart not 
being dilated. 

Open Ductus Arteriosus or Ductus Botalli. 

This is a very rare congenital defect. There are in the literature 
only 20 cases of uncomplicated open ductus arteriosus in which the 
autopsy confirmed the clinical diagnosis. Of these, only 5 occurred 
in infants under one year of age, and 5 others ranged from the first 
to the tenth year (Vierordt). The complicated cases occur with 
stenosis of the pulmonary artery, septum defects of small extent, and 
open foramen ovale. 

Physical Signs. — Cyanosis is not present in the majority of cases, 
or if present is so only intermittently and is not marked. 



CONGENITAL DEFICIENCY OF THE VENTRICULAR SEPTUM. 441 

The murmur is a loud buzzing systolic murmur heard with 
greatest intensity over the pulmonary artery, and not conducted 
downward, but conducted to the left of the sternum into the veins 
of the neck (Hochsinger). 

There is an accentuated second pulmonic sound which can be 
heard in the enrol id*. 

Right Ventricle. — The presence of hypertrophy of the right ven- 
tricle tends to confirm the diagnosis ; if the left ventricle is also 
hypertrophiedj greater certainty is added. This is of great moment, 
since hypertrophy of the left ventricle is not present in any of 
the other congenital defects, except those connected with the 
anomalies of the aorta and aortic system and which have only a 
scientific value, since the literature contains no cases which have 
been diagnosed during life. The dulness in the second space referred 
to under Pulmonic Stenosis is also of value. 

Congenital Defects of the Auricular Ventricular Septum ; De- 
fects of Auricular Septum ; Open Foramen Ovale. 

Inasmuch as 44 per cent, of the autopsies upon individuals who 
during life showed absolutely no signs of cardiac disturbances reveal 
a patency of the foramen ovale, the diagnosis of the condition as an 
uncomplicated entity should be made with great reserve. This con- 
genital defect is generally found to exist in connection with other 
defects of a congenital nature (stenosis of the pulmonary artery). 

Cyanosis has been found in all the cases in which autopsy has 
been made. In a case recorded by Foster, there was cyanosis with 
a varying systolic and presystolic murmur at the sternal end of 
the third or fourth costal cartilage. 

Walshe says that it can hardly be asserted positively that a 
patency of the foramen ovale may of itself cause a murmur. 

Congenital Deficiency of the Ventricular Septum — 
Maladie de Roger. 

Autopsies have shown that this condition may exist during life 
without giving any signs of its presence. Moreover, it is so often 
combined with other congenital heart anomalies, such as stenosis of 
the pulmonary artery or ostium, that the signs of the ventricular 
condition must of necessity be obscured by those of the complicating 
defect. 

Cyanosis has been present in some cases of uncomplicated ven- 
tricular septum defect (Mfiller) and absent in others, it is present 
in the ca-es complicated with pulmonary stenosis. 

Murmur. — According to Roger, a loud systolic murmur is heard 
over the whole praecordium, toward the median line, over the upper 



442 DISEASES OF THE HEART AND PERICARDIUM. 

third of the cardiac area. According to others (Miiller), the murmur 
has no special point of greatest intensity. It is not conducted into 
the vessels of the neck. 

Rauchfuss calls attention to the fact that with this murmur the 
distinct valvular character of the heart-sounds at the various valves 
should be heard. The case of Miiller was that of a cyanotic 
infant two months old. A loud murmur having no special point 
of greatest intensity was heard over the whole cardiac area. The 
valvular sounds were distinctly heard. Autopsy showed uncom- 
plicated defect of the ventricular septum. 



ACUTE ENDOCARDITIS. 

Acute endocarditis is an inflammation of the lining membrane of 
the heart. That covering the valves and their immediate vicinity is 
the part generally affected. There is also an inflammation, slight or 
marked, of the muscle tissue of the heart, and in some cases there 
is inflammation of the pericardium. Endocarditis thus involves 
structures of the heart other than the endocardium. Acute endo- 
carditis may be benign or malignant. Between the two extremes, 
there are all gradations as to severity. All forms of endocarditis 
are caused by infection which in the malignant variety is of the 
severest septic type. Foetal endocarditis affects the right side of 
the heart ; after birth, the left heart is chiefly affected. The condition 
is less frequent before than after the fifth year of life, and occurs 
with equal frequency among boys and girls (Steffen). 

Etiology. — Acute endocarditis occurs most frequently with acute 
articular rheumatism, but may appear in any infectious disease. It 
is often found in scarlet fever ; less often in measles. I have seen 
it in rare cases of erythema nodosum (2 cases). It may occur with ty- 
phoid fever, diphtheria, influenza, pneumonia (Netter), cerebro-spinal 
meningitis, and tuberculosis. In fact, all forms of sepsis, such as 
osteomyelitis, either foetal or in the newborn infant or in children, 
may be accompanied by endocarditis. Endocarditis is present in 
16 per cent, of the cases of chorea and is always present in fatal 
cases of that disease. 

Bacteriology. — The most important bacteria bearing an etiolog- 
ical relationship to endocarditis are the streptococci of the various 
varieties and the Staphylococcus pyogenes. Harbitz divides endo- 
carditis into the infectious and the non-infectious varieties. He found 
bacteria in the vegetations in most of the infectious cases, streptococci 
in 39.5 per cent, and staphylococci in 18.6 per cent, of the cases; 
other bacteria, such as the pneumococci, were also found. The cases 
in which no bacteria were found were healed cases. He thinks that 
the staphylococci most often cause pysemic endocarditis with ulcera- 



ACUTE ENDOCARDITIS. 443 

tions and metastatic abscess. Welch has, however, found strepto- 
cocci in ulcerative endocarditis, and docs not fully accept the view 
of Harbitz. The Diplococcus pneumoniae is next in importance as an 
etiological factor. Wright found the Bacillus diphtherial in one case. 
Other bacteria, such as the Gonococcus, the Bacillus endocarditidis 
griseos (Weichselbaum), the Micrococcus endocarditidis rugatus and 
capsulatus, the Diplococcus tenuis (Klemperer), have been found in 
cases of adult endocarditis. Although they are all, as well as the 
Bacillus typhosus, doubtless capable of causing the same process in 
children, actual clinical cases are still to be published. 

All forms of endocarditis are thus septic processes due to the 
circulation in the blood of bacteria or their toxins. In some cases 
it is possible to discover the poiut of entrance of the bacteria into 
the circulation, in others, it cannot be fixed upon. The forms of 
endocarditis are not so uncommon in infants as is supposed. The 
tonsil is a great avenue for the entrance of bacteria or toxins into 
the circulation (Cheadle). It is believed that many cases of endo- 
carditis in children originate in this manner (Packard). I have 
frequently met with endocarditis in which the only other clinical 
manifestation was a slight redness or swelling of the tonsils. The 
integrity of the endothelium of the endocardium must be compro- 
mised if bacteria have invaded the tissue of the valvular endocar- 
dium (Prudden). It is supposed that the toxins produced by the 
bacteria circulating in the blood reduce the resistance of the endo- 
thelial lining of the endocardium, thus preparing the soil for bac- 
terial invasion. 

Morbid Anatomy. — In some cases the only lesion is a swelling 
of the valves. They are thickened and succulent, their surface being 
smooth. The basement substance is swollen and there is an increase 
of connective-tissue cells (Delafield). In other cases the borders of 
the valves present transparent, gelatinous, whitish-yellow or reddish 
formations, varying from the size of a pin's head to that of a bean. 
These are irregular in shape, cover both surfaces of the valves, and 
may be single or multiple. They are also seen on the chordae 
tendineae. The free border of the valve is warty or papillomatous 
(endocarditis verrucosa or polyposa) (Ziegler). The papillae may ap- 
pear on the free surface of the valves. There may be a loss of sub- 
stance with the formation of adherent thrombi of a whitish or reddish 
color and of tenacious consistency (endocarditis ulcerosa). Small foci 
of pus may be present in the heart substance (endocarditis pustulosa). 
Bacterial invasion of the surface of the valves results in loss of sub- 
stance, formation of thrombi, and changes in the nuclei of the con- 
nective tissue (necrobiosis). The mitral valve being more vascular is 
sooner affected than the aortic or pulmonary valves. Kxudation on 
the valve i- replaced by new connective tissue; excrescences and new 
formations become permanent. If the bacteria penetrate deeply, 



444 



DISEASES OF THE HEART AND PERICARDIUM. 



thickening of the valve results. Large thrombi are organized, and 
the valves become shrunken and distorted. Ulceration and loss of 
substance may result in perforation of the valves. The thrombi 
just mentioned are sometimes made up of blood-plates ; in other 
cases leucocytes, blood-cells, and fibrin in varying amounts are 
present. 

There may be exudative pericarditis. The myocardium is the 
seat of degeneration, which leads to dilatation, or to abscess or 
aneurism of the heart muscle. Through the separation of portions 
of the thrombi or of the vegetations on the valves, these particles 
may be carried into the circulation. Containing, as they do, bacteria 
(mycotic emboli), they cause secondary infections with necrosis or 
abscess in the kidney, spleen, and brain. 

The symptoms of acute endocarditis are those of some general 
infection. They are not in infants and children so characteristic as 
to direct attention to the heart. Infants cannot and children do not 



Fig. 128. 



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of 

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33 







Endocarditis complicating influenza. Second week of the illness. Mitral systolic mumur 
developed under observation. Female child, four years of age. 

complain of pain, palpitations, or feelings of uneasiness in the heart 
region as adults sometimes do, and therefore unless the heart is care- 
fully examined as a routine procedure, the simple cases of endocar- 
ditis will escape observation. The most interesting cases are those 
which begin with all the symptoms of an attack of influenza or 
tonsillitis. There are fever, rapid pulse, and an increase of the 
respirations to 36 or 40. The fever, however, does not subside in 
the time occupied by the course of one of the above affections ; it 
continues high, 103°-104°-105° F. (39.4°-40.5° C), with morning 
or afternoon remissions. In such cases a most careful examination 
of the lungs and other organs, fails to reveal anything abnormal. 
The heart, however, shows the presence of endocardial inflammation. 
In some obscure cases, there is an increasing pallor with a slight daily 
rise of a half a degree or a degree in body temperature, which will 
continue for days or even weeks and give rise to a suspicion of 



SEPTIC, ULCERATIVE, OR MALIGNANT ENDOCARDITIS. 445 

paludal poisoning. There is also an increasing pallor. Examination 
of the heart reveals the lesion. In other cases there are a very 
slight but increasing pallor, weakness and indefinite pains in the 
bones and joints. There seems to be a general septic infection. The 
rheumatic eases are as a rule easily diagnosed. The heart should be 
regularly examined in such cases. The endocarditis which compli- 
cates chorea sometimes runs its entire course without any marked 
rise in the body temperature. I have, however, been able in 
such eases to confirm the statement of Jiirgensen, that the normal 
diurnal temperature variations are distorted — that is to say, the 
morning temperature may be higher than the evening tempera- 
ture. In other cases of chorea there is a distinct rise of tem- 
perature without any increase of the respirations and pulse-rate 
during the active stage of the endocarditis. After the symptoms 
of chorea have begun to decline there is occasionally a rise of 
temperature lasting a day or more, which may indicate a slight 
recurrence of the endocarditis. In other cases I have observed 
a subnormal temperature of a degree or more lasting for days. This 

Fig. 129. 



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Chronic cardiac disease, hypertrophy, and dilatation of the left and right ventricles. 
Enlarged liver and spleen, ascites, cyanosis, recurrent attacks of endocarditis. Tempera- 
ture by rectum shows a subnormal range. Boy, twelve years of age. 

occurred in a case of recurrent endocarditis. Thus the temperature 
is not at all characteristic. The heart in children is extremely ir- 
regular. It may vary from 60 to 120 per minute within a few days, 
and may vary at different times of the same day. Under such con- 
ditions it may be surmised thai there is a myocarditis. The res- 
pirations are increased. The children do not complain of the heart. 
In pneumonia, Bcarlet fever, and measles, the endocarditis is 
masked by the symptoms of the primary disease. 



Septic, Ulcerative, or Malignant Endocarditis. 

This form of endocarditis I8 ran- in infants and children. Adams 
collected from the literature 17 cases in children. The sexes were 
about equally affected. Three cases were congenital and 8 were 



44 (> 



DISEASES OF THE HEART AMD PERICARDIUM. 



five years of age or under. The others ranged up to fourteen 
years. The trend of opinion (Adams) supports the contention 
of Lazarus, Barlow, and Weichselbaum, that these cases differ 
from the benign cases only in regard to severity. Dreschfeld 
divides these cases into the following classes : (a) the primary 
form, (b) the form complicating septic disease, (c) the form compli- 
cating pneumonia and meningitis, (d) the form which occurs as a 
mixed infection due to septic organisms in the acute infectious 
fevers or which is secondary to the rheumatic affections of the valves. 
I have recently observed two cases of septic endocarditis. In one, in 
a boy with osteomyelitis of the tibia, staphylococci were found in the 
blood during life. In the other case, which followed a pneumonia, 
streptoccoci were found in the blood during life. In the former case 
hemorrhagic symptoms and signs of severe cardiac disease, such as 







































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Fatal septic endocarditis following a pneumonia. Streptococci found by culture in the blood 
during life. Girl, eight years of age. 



gallop-rhythm, were observed. The latter case was seen in my hos- 
pital service. The child, a girl of eight years, had had a pneumonia 
three weeks previous to her admission. She had apparently recovered, 
had sat up in bed after ten days, and was about. A day before her 
admission the temperature mounted to 104° F. (40° C), she vom- 
ited, and had diarrhoea. The child showed much prostration, and 
on examination an area of consolidation was found in the right 
lung behind. She had an active endocarditis giving a mitral sys- 
tolic murmur. The liver and spleen were large ; the temperature 
rose and fell twice daily, chills and dyspnosic attacks preceding each 
rise. The temperature subsided to the normal or subnormal after each 
rise. There were nausea, vomiting, and signs of cardiac failure. The 
heart did not at first show any enlarged area of dulness. After a few 
days the left ventricle showed an increased area of dulness to tho 



SEPTIC, ULCERATIVE, OR MALIGNANT ENDOCARDITIS. 447 

extent of '1 to 3 centimetres outside the nipple-line (acute dilatation), 
with diffusion of the apex-beat. The right ventricle was dilated. 
With the extreme fluctuations of temperature, the child became deli- 
rious. The heart, as at the time of admission, showed a mitral 
systolic murmur. After ten days petechia? appeared, first on the 
neck and upper thoracic region, and increased both in number and 
extent The face and eyes became cedematous (cardiac failure). The 
patient became unconscious and died in coma with Cheyne-Stokes 
respiratory phenomena. The blood withdrawn during life showed in 
culture the presence of long streptococci. 

The diagnosis of septic endocarditis rests on the history and 
the presence of cardiac signs, the prostration, the great fluctuations 
in temperature resembling those in sinus thrombosis in ear disease, 
the onset of chills and delirium, the presence of petechia?, and 
lastly on the results of examination of the blood for bacteria. 

Of great interest in this connection, are the cases of chronic 
recurrent endocarditis which toward the close of the disease have 
certain symptoms resembling those of the septic or so-called ma- 
lignant cases. In a child of ten years suffering from chronic 
recurrent rheumatic endocarditis, there was toward the close of the 
illness a period during which phlebitis with thrombosis of the deep 
veins of the neck and arms on both sides and oedema of the corre- 
sponding extremities developed successively. After a few weeks the 
symptoms of phlebitis and thrombosis gradually subsided and there 
was a period of a few weeks during which the patient was much im- 
proved. The fever and anasarca subsided and the heart action was 
good. Before the fatal issue the endocarditis recurred and there were 
fever and what appeared to be significant petechia? on various portions 
of the body. The case was a rheumatic one and had been under ob- 
servation for two years. Its outcome gives weight to the theory 
that a seemingly benign endocarditis may at any time take on a ma- 
lignant or septic nature. 

Physical Signs of Acute Endocarditis. — A murmur which 
develops while a child is under observation is indicative of acute 
endocarditis. 

Inspection may reveal nothing abnormal, or there may be extreme 
irregularity of the action of the heart. There may be increased 
action, as evinced by visible pulsation over the cardiac area. 

Palpation also may reveal nothing abnormal ; there may be a 
thrill over the apex. 

Percussion at first reveals nothing. In some cases there is a 
slight dilatation of the left ventricle (Steffen) as the disease pro- 
gresses. I have seen this dilatation in cases in which the condition 
had existed for a week. During convalescence the dilatation may 
retrograde and the heart confines return to their normal limits. 

Auscultation. — In the majority of cases, a soft systolic murmur 



448 



DISEASES OF THE HEART AND PERICARDIUM. 



is heard over the apex and the mitral area. There is rarely a pre- 
systolic murmur. There may be murmurs at the other valves, 
having the characteristics of the same murmurs in the adult. In 
any acute disease, the physician should be careful to observe a mur- 
mur very carefully before pronouncing it organic. I have found 
murmurs, especially in typhoid fever in young and older children, 

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Chronic cardiac disease; great cardiac dilatation; recurrent attacks of endocarditis-, 
phlebitis and thrombosis of the deep veins of the neck and arm on both sides successively ; 
oedema of the corresponding arm and forearm ; great dilatation of the superficial cervical 
and thoracic veins. Female, ten years of age. 



which appeared and disappeared. Such murmurs are hsemic or myo- 
carditic and functional ; they are very gentle, generally systolic, and 
are limited very closely to the apex or pulmonic area. They are not 
conducted and there are no positive signs of dilatation. Jacobi has 
met pulmonic murmurs in very young infants, which were at autopsy 



ACUTE LWDOCARDITTS. 



449 



shown to be functional. On the other hand, if a murmur is dis- 
tributed over a valvular area, takes the place of the valvular sound, 
is conducted into the arteries, and occurs in connection with signs 
of dilatation, the physician is justified, acute symptoms being in 
evidence, in assuming the presence of organic disease. 

Course and Prognosis. — Many eases of endocarditis, especially 
those not of rheumatic origin, run their course, do not recur, and in 
after-life give no symptoms referable to the heart. Others run an 
acute course without developing any physical signs until convales- 
cence. I have seen such form- follow chorea. The murmur devel- 
ops in the intervals of freedom from symptoms of chorea. Rheumatic 
cases are likely to recur, and in this tendencv lies the danger. The 
prognosis as to immediate recovery is very good in all of the ordi- 
narily severe cases of acute endocarditis. The severer septic or 
malignant cases give a grave prognosis. The future of cases of 

Fig. 132. 



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Recurrent endocarditis with acute articular rheumatism which developed under observation. 
Boy, twelve years of age. 

acute endocarditis which have recovered will depend very much on 
the immediate management. I have seen patients who had been 
allowed to be up and about too early and to participate in sports, 
develop after a few months symptoms resembling those seen in 
acute dilatation due to heart strain. These cases show a marked 
dyspnoea on exertion and cyanosis after play. The children are 
easily fatigued. They have pain and uneasiness over the region of 
the heart after running. On percussion an abnormally large heart 
area is found. 

The treatment of acute endocarditis is directed toward limiting 
the damage done by the disease to the heart. Rest in bed is neces- 
sary. The patient should not be allowed to maintain the sitting 
posture, but should be recumbent. The rest should be continued 
long after the subsidence of the active symptoms. The symptoms 
and physical signs are the guide- as to its duration. W there have 
been marked disturbance of the heart action and distincl dilatation 
of the ventricle with signs of myocarditis such as great irregularity 
of the pul-e. the Stay in bed should be prolonged for weeks. 



450 DISEASES OF THE HEART AND PERICARDIUM. 

If the action of the heart is rapid and tumultuous, an ice-bag 
should be placed over the cardiac area. This remedy is also useful 
in cases in which the heart action is not very rapid, but in which 
there are nevertheless signs of active inflammatory disturbances. 

Salicylate of sodium is a favorite remedy, not only in cases 
with a rheumatic history, but also in septic cases. The dosage is 
grains j to ij (0.6-0.12) every few hours for infants and young 
children ; older children receive more. Some children have stomach 
pains and disturbances after taking salicylates. There must then in 
the rheumatic cases be substituted some alkali, such as bicarbon- 
ate of sodium. I have administered aspirin in many cases with ap- 
parent benefit. A few drops of the tincture of digitalis will be use- 
ful in regulating the heart action late in the disease. Digitalis is 
given for periods of a few days and then suspended for a time, after 
which it may again be given if necessary. Care should be taken to 
support but not to drive the heart. The diet should be light, fluid, 
and easily assimilable. The bowels are best regulated with some 
saline cathartic or by rectal enemata. 

The temperature, if high, may be treated in the same way as in 
other acute diseases. Baths of low temperature should not be given. 
The temperature in this disease is of so short duration that in the 
majority of cases sponging with cold water is effective. The man- 
agement of choreic cases will be discussed in the section on Chorea. 

The injection of antistreptococcic serum in the septic cases has 
not given satisfactory results. 

CHRONIC HEART DISEASE. 

The lesions in chronic valvular disease in infancy and childhood 
are the same as in the adult subject. 

The etiology has been considered in the section on Endocarditis. 

Frequency. — Of 70 of my cases of chronic valvular disease, 37 
were of the female and 33 of the male sex ; 2 were below the age 
of two years ; 24 from the second to the fifth year, and 39 from the 
fifth to the tenth year of life. In 50 of the 70 cases the mitral 
valve was involved, causing either a systolic or a diastolic murmur, 
or both. The following table will give an idea of the relative fre- 
quency of the valvular lesions : 

Mitral insufficiency 26 cases. 

Mitral stenosis 6 

Mitral insufficiency and stenosis 18 " 

Aortic stenosis 6 

Aortic stenosis and insufficiency 1 case. 

Endocardial and pericardial disease 5 cases. 

Combined lesions of mitral and aortic valves 8 " 

The physical signs, the reservations noted in the section on 
cardiac murmurs being made, are the same as in the adult subject. 



CHROXIC HEART DISEASE. 



451 




On the other hand, certain characteristics of the disease in childhood 
are not common to the adult subject. There are cases of chronic 
cardiac disease in infancy and childhood which escape recognition 
because the heart is not examined with sufficient care. Murmurs of 
mild intensity pass unrecognized. 

There are cases of endocarditis which run an obscure course, give 
very few symptoms, and which are apt to recur at the onset of 
tonsillitis or an attack of influenza. These cases of chronic endo- 
cardial disease give very tew symptoms in the intervals between the 
attacks. There may be obscure pains in the limbs or joints which 
arc not interpreted by the physician as purely rheumatic, but are 
believed to be of a grippal char- 
acter. The patients may eventu- Fig 133. 
ally develop symptoms of seri- 
ous cardiac insufficiency. The 

- of chronic valvular dis- 
ease resulting from an attack 
of some infectious disease may 
leave the heart little compro- 
mised. It is true that upon ex- 
amination a cardiac murmur 
which may be marked or slight 
is heard, but the cases have no 
subjective symptoms. They 

have what is called by the German School a healed endocarditis. 
They may, however, develop serious cardiac symptoms at the onset 
of an infection of the gut or other organs. The heart in these cases 
may be called irritable. The patients do not develop inflamma- 
tion of the endocardium or pericardium as do the rheumatic case-. 
On slight disturbance of the gut or intestines, such a heart, even 
when there is no fever, acts very much like a hypertrophied organ. 
There is an increase not only of the frequency, but also of the force 
of the heart'- impulse. The vessels are also affected, and there is a 
bounding full pulse at the radial. As a result of the infection and 
of tiie congestion brought about by the increased action of the heart. 
there will be albumin and casts in the urine. These symptom- sub- 
Bide and do not recur except at long interval-. In the intervals, 
with the exception of a valvular murmur, there are absolutely no 
Bigns of cardiac disease. In children, cases with a -light or marked 
valvular lesion which are apparently at a standstill, give certain 
-ymptoms which are significant of defective cardiac action. On ex- 
ertion, the children complain of pain in the side or the epigastrium. 
Examination will .-how little change in the cardiac areas. The 
valvular murmur i- heard. Such hearts are also irritable. 1 have 
often found a distinct history of palpitation occurring ;it intervals 
and even in the absence of exertion. Many children with chronic 



Simple mitral insufficiency : dilatation of the 
kit ventricle. Girl, six years of age. 



452 



DISEASES OF THE HEART AND PERICARDIUM. 



cardiac disease of a very mild and absolutely quiescent type, exhibit 
a persistent pallor which does not yield to drugs. Children without 
other symptoms complain of headaches after slight excitement. Ex- 
amination will, in these cases also, show a slight hitherto unrecog- 
nized chronic cardiac valvulitis. Slight oedema of the eyes which is 
persistent should direct attention to the heart. 

Fig. 134. 




Chronic cardiac disease; dilatation of the right and left ventricles. 

Boy, six years of age. 



Epigastric pulsation. 



Many cases without any other signs of chronic cardiac disease 
show a slight evanescent trace of albumin in the urine. 

There may be absolutely no signs of cardiac insufficiency or 
change in the physical character of the organ. Children with signs 
of quiescent cardiac disease often have obscure attacks of faintness 
and vomiting, following every little excitement. 

There are also the rheumatic recurrent cases of endocarditis in 



CHRONIC HEART DISEASE. 45: 



childhood. These exhibit very much the same symptoms of cardiac 
insufficiency as the corresponding eases in adults, viz., enlarge- 
ment of the liver and spleen. Children appear to recuperate 
more rapidly than adults, but, on the other hand, the attacks are 
more likely to recur in them than in older subjects. A compro- 
mised heart in a child will hear more strain than in an adult. Cases 
are frequently seen in which children show on physical examina- 
tion marked chronic disease, but are notwithstanding exceedingly 
active and show no symptoms referable to the heart. The signs of 
insufficiency of the cardiac muscle are the same in children as in the 
adult. There is dyspnoea on exertion, slight oedema of the general 
surface, and enlargement of the liver and spleen. In the later stages, 
there are transudates in the pleura and abdomen. In some cases, es- 
pecially where there is progressive interstitial myocarditis with 
adherent pericardium, the pleura may show unilateral transudate. 

In cases of cardiac insufficiency, the pulse is persistently high or 
very irregular. There i< persistent dyspnoea. Children with cardiac 
disease suffer, as a rule, less than adult subjects. 

Cardiac angina is not an uncommon symptom in case- of aortic 
disease. It is present in cases in which there are signs of lack of 
compensation. The angina come- on in attacks occurring chiefly at 
night, and is very severe. I have seen a boy of eight years with an 
aortic murmur suffer from these attacks for days. In such cases there 
are a dilated ventricle and an enlargement of the liver and spleen. 

The prognosis of chronic valvular disease in childhood depends 
very much on the type of disease. If the heart is only slightly 
affected and the patient not a rheumatic subject, the outlook is good. 
With careful management all ill after-effects can he avoided ; chil- 
dren thus affected may grow to adult life without suffering from any 
symptoms referable t<> the heart. If, on the other hand, they are 
attacked by any intercurrent disease, such a- scarlet fever, the heart 
may again become the seat of inflammatory processes. The patients 
may, however, recover and continue free from symptoms for years. 
The rheumatic cases give the most unfavorable prognosis. These 
are prone to recurrent attacks of endocarditis, each attack leaving 
the heart in a more weakened condition than before. Most of my 

- have been in children who, having had one attack of rheu- 
matic endocarditis, suffered from the affection to a greater or lesser 
degree for years. Within a few years of the first attack they succumb 
to progressive non-compensatory cardiac < 1 i - < •<• i - « • . 

Treatment. — .Many cases of cardiac disease in infancy and child- 
hood give no symptoms and need very little treatment beyond careful 
and judicious management Children thus affected should have a 
can-fully regulated dietary, and should not indulge in sports which 
subject the heart t«» -train. They should not ride the bicycle, hut 
may, however, indulge in many of the amusements of children, 



454 DISEASES OF THE HEART AND PERICARDIUM. 

such as skating, roller skating, swimming to a moderate degree, and 
horseback exercise. They should be under constant observation, and 
when attacked by any acute infection however slight should be put 
to bed, and kept quiet until long after convalescence. In these cases 
an antirheumatic course is pursued even although the illness be only 
a mild attack of influenza or tonsillitis. It is well to give the sali- 
cylates in small doses for several days and to keep the bowels open 
with some alkaline cathartic. With children who suffer from rheu- 
matism, the nature of the primary disease should not be forgotten. 
They should have constant antirheumatic treatment even when the 
cardiac disease is at a standstill. Heiman has recently shown the 
beneficial effects of the intermittent administration of salicylates in 
these cases. I have carried out that method for some time. Alkaline 
baths of the Nauheim form are of great utility in alleviating the 
subacute rheumatic pains from which these subjects suffer, and this 
treatment also tends to keep the rheumatic tendency in abeyance. 
Such children should be kept under constant observation. The tem- 
perature should be taken twice daily. Any rise of temperature should 
be regarded as a threatening sign and the patients put to bed for 
perfect rest until the crisis has passed. In cases in which there is 
marked dilatation or pericardial involvement, any exacerbation of 
symptoms is a signal for immediate rest in bed. Slight oedema of 
the surface and swelling of the liver and spleen will subside if 
treated with perfect rest, a light assimilable diet (milk), and mild 
alkaline catharsis. It is not always necessary to use digitalis. If 
given at all, it is best administered in the form of the infusion. 
I am accustomed to use this drug for a period of two or three days, 
after which I discontinue it. There is no doubt that its action con- 
tinues after the administration is stopped. Convallaria in the form 
of the fluid extract is at times one of the most useful remedies in 
cases in which digitalis has failed to give relief. If there is great 
dyspnoea or orthopnoea, codeine in moderate doses should be used. 
Young children do not bear morphine well. It certainly should 
not be used hypodermatically. In aortic disease in older chil- 
dren, nitroglycerin in doses of grain T -i- T (0.0006) relieves the 
angina. I administer morphine only to older children, and then 
only when the nocturnal attacks of angina are very severe. I have 
not found strychnine very useful in the chronic forms of cardiac 
disease. Caffeine in moderate dosage seems more useful in correcting 
the irregularity of the pulse or bradycardia seen in some of these 
cases. In combination with digitalis it gives excellent results. If 
ascites appears, the patient should be promptly tapped to relieve the 
circulation and the abdomen supported by a binder. If there is a 
pleuritic effusion at the same time, it should not be disturbed. With 
relief of the abdominal distention, the pleuritic effusion often dis- 
appears. 



CARDIAC MURMURS IN INFANCY AND CHILDHOOD. 455 

CARDIAC MURMURS. 

Cardiac murmurs which arc the result of disease or insufficiency 

of the valves of the heart have the same general character as those 
in adults, the following being the chief points of' difference : 

(i. Cardiac disease of a very serious character may exist (as in 
congenital cyanosis) without any murmur. 

b. Cardiac murmurs are as a rule louder in children than in adults. 
The loudness is therefore no guide as to the seriousness of the affection. 

c. Cardiac murmurs in children are sometimes heard loudly 
conducted over the whole chest ; diagnosis of disease of a particular 
valve must be based on the greatest intensity of the murmur at that 
point. 

d. Haemic and dynamic murmurs in children under four years of 
age are not so common as is supposed. There should be no hesitation 
in making the diagnosis of organic affections in systolic, basic, or 
apex murmurs if there are distinct conduction or signs of dilatation 
or hypertrophy. This is especially to be remembered in chorea, 
extreme anaemia, and in febrile affections where rapidity in time and 
rhythm (galloprhythms) causes adventitious sounds. 

e. The conduction of the aortic murmurs into the arteria femoralis 
occurs in occasional cases in children. Pulsation of the liver or 
spleen, as found in aortic disease of adults, is not present in children 
(StefFen). 

Accidental Cardie Murmurs in Infancy and Childhood. 

Accidental murmurs are divided into those heard over the heart, 
in the arteries, and in the veins. The study of the accidental murmur 
of the heart in infancy and childhood has been much neglected. 
West and Hochsinger give the most valuable data. The principal 
points of difference between the murmurs in infants and children 
and those in the adult are as follow- : 

Cardiac Murmurs. — Anaemia. — The severest forms of anaemia 
sometimes fail to give haemic murmurs. Not one of 200 cases under 
fonr years of age examined by EEochsinger gave anaemic murmurs. 
After the fourth year and up to the seventh year of life the fre- 
quency of the anaemic and haemic murmurs increases. I have in 
very exceptional pernicious anaemias found a mild blowing basic 
murmur. Oik- such case occurred in a child under four years. 

Feoers. — The haemic murmur- bo common in the febrile affections 

of adult life are rarely heard even in severe febrile affections with 

anaemia, in patient- under the age of three years. I have heard 
them in children under thro years of age, with severe typhoid fever. 
They are common in typhoid fever in older children. 



456 DISEASES OF THE HEART AND PERICARDIUM. 

Characteristic* of Ancemia Murmurs. — These never occur with 
signs of cardiac dilatation or hypertrophy. They are not conducted 
into the arteries. They never entirely take the place of the valvular 
cardiac sounds, but accompany them. They are soft bloiving 
murmurs, heard at times most loudly at the pulmonary valve, some- 
times heard over the base and whole prsecordium, and faintly 
heard at the apex. They are never heard at the aortic or tri- 
cuspid valves, or behind. They are inconstant, disappearing for a 
time and again appearing at the various points of the chest. 

Accidental Arterial Murmurs. — The theory held by some 
observers, that pressure of the stethoscope on the arteries of the 
neck may cause a murmur, should be entertained with caution. Cor- 
rect stethoscopy will hardly lead to such an error. A murmur in 
the large arteries of the neck is conducted from the heart and is 
invariably organic in origin. I have heard aortic murmurs con- 
ducted in the femoral artery. 

Venous Hum. — Although cardiac accidental murmurs due to 
anaemia are rarely heard in children, the venous hum due to the 
same cause is frequently heard. In young infants and children it is 
present in the veins of the neck, is quite loud, and is heard at either 
side of the upper part of the sternum. If there is anaemia due to 
valvular cardiac disease, the venous hum is heard in the arteries of 
the neck, with the organic murmur. 



MYOCARDITIS. 

Myocarditis is very frequent in infancy and childhood. Most 
of the knowledge of this condition has been obtained from a study 
of the disease in young subjects. This is due to the fact that in 
early life the heart is especially exposed to the deleterious action of 
the toxins of the infectious diseases. Myocarditis is a degeneration 
or inflammation of the muscular substance of the heart, secondary to 
the action of poisons (phosphorus) to the toxins of bacteria (as in 
the exanthemata, typhoid fever, diphtheria, pertussis, sepsis, osteo- 
myelitis), or to the changes consequent upon disease of the peri- 
cardium, or endocardium, of rheumatic or infectious origin. 

Morbid Anatomy. — If there is degeneration of the myocardium, 
only the muscular fibre may be the seat of fatty changes. There 
is an increase of fat drops in the muscular tissue of the heart. In 
advanced conditions, the fatty changes are apparent to the naked eye 
as a yellowish discoloration beneath the endocardium. In other cases, 
there is a granular or hyaline degeneration of the muscle fibre or 
a vacuole formation. The cell protoplasm becomes cloudy, hyaline, 
loses its striation, and disintegrates or is replaced by drops of fluid. 
This occurs in diphtheria, typhoid fever, pneumonia, chronic con- 



MYOCARDITIS. 457 

gestion, and in toxaemia of various kinds. Thrombi may form in 
hearts which are the seat of advanced degeneration. In toxaemia 
and the infections diseases, there is inflammation of the myocardium. 
There is an invasion of the muscle tissue by bacteria from the endo- 
cardium (staphylococci, streptococci, and pneuinococci). In such 
cases, there are also grayish or yellowish discoloration of the muscle 
tissue, vacuolization, and granular and hyaline degeneration. The 
muscle tissue is the scat of small ceil infiltration or there may be 
abscesses o{ microscopic or macroscopic size. If recovery occurs 
these areas may cicatrize with connective tissue. Tuberculous 
and syphilitic inflammations of the myocardium occur, but arc 
uncommon. 

Etiology. — The degenerative or inflammatory changes may be 
caused by the direct action of the bacteria (Almquist), but usually 
the influence of the bacteria themselves is only slight, since they do 
not find in the myocardium a favorable soil for growth. The toxins 
of these bacteria produced either elsewhere in the economy and 
circulating in the blood, or in the heart muscle itself, are chiefly 
instrumental in causing the degenerative changes (Welch, Flexner, 
Schamshin). Fever, as such, has only a slight influence in caus- 
ing myocarditis (Werhofsky). 

The symptoms of myocarditis can best be understood by study- 
ing the heart in the various infectious diseases. In diphtheria, 
myocarditis may be suspected if there occur sudden syncope, faint- 
aess, chilly sensations, vertigo, and vomiting. The patients com- 
plain of precordial weakness ; there are all the symptoms of collapse 
and a flickering, irregular pulse. These phenomena may appear 
at intervals throughout the disease and persist far into convales- 
ce ice. 

In acute forms of pneumonia in which the toxaemia is very great, 
infants may, even at the outset, exhibit cardiac weakness. There are 
-light cyanosis of the lips and abnormal pallor of the face and gen- 
eral surface. The heart action is more rapid than in other cases of 
pneumonia in which the lung lesion is quite as extensive. At the 
crisis, the action of the poison on the heart is evinced by an irregu- 
larity or arhythmia of the pulse. The pulse may he extremely slow 
(bradycardia). In septic conditions there will, late in the disease, be 
galloprhythm, distortion of the pulse-respiration ratio, cyanosis, 
and extreme precordial distress. Henoch, Osier, and I have shown 
that there may be degenerative changes in pertussis. These are clini- 
cally apparent in cases which have extended over a long period. A 
constant dyspnoea, an abnormally high pulse-rate, drowsiness, dis- 
inclination to exertion, and slight oedema of the face and other parts 
of the body are present. In rare cases physical examination reveals 
a slight dilatation of the right ventricle. In other cases there is 
;it the apex a faint systolic murmur of purely muscular origin. In 



458 DISEASES OF THE HEART AND PERICARDIUM. 

adherent pericardium, the advance of the process into the myocar- 
dium is indicated by the symptoms above detailed. 

The myocarditis of chronic valvular disease is a progressive 
process. It manifests itself by the signs of lack of compensation 
described in the section on Chronic Cardiac Disease. The varying 
pulse, the dyspnoea, the enlargement of the liver and spleen, and 
transudates into the serous cavities, all indicate this form of pro- 
gressive weakness of the cardiac muscle. 

Diagnosis. — Although the diagnosis cannot in all cases be made 
with absolute certainty, the presence of the condition may be sus- 
pected if the following sets of symptoms appear at regular intervals 
in the course of the disease — attacks of palpitation and faintness, 
pallor, cardiac irregularity, gallopryhthm and weakness of the apex 
beat and of the first muscular sound of the heart, with intensifica- 
tion of the second pulmonic sound. 

The treatment should support the heart and lessen its work, and 
should also be directed toward the management of the primary 
condition. In all of these cases, prolonged rest for the heart, con- 
tinued long after convalescence, is of primary importance. It 
should not be forgotten that even in a degenerated organ there 
is healthy tissue on which the drugs and treatment act. These 
healthy foci should be sustained, and not exhausted by the action 
of powerful drugs given in large doses. Degeneration cannot be 
cured by drugs ; nature must heal the diseased areas. 



PERICARDITIS. 

Pericarditis is an inflammation of the pericardium due to infec- 
tion, which may take place through the blood- or lymph-channels 
or may occur through contiguity to infected areas in neighboring 
structures. The existence of primary pericarditis or so-called idio- 
pathic pericarditis apart from rheumatism or infection is a matter of 
doubt. It is therefore to be regarded as secondary to other condi- 
tions or the result of direct systemic infection. 

Occurrence. — Pericarditis occurs in foetal life (Billard, Tardieu, 
Heiter) ; Bednar describes cases in newly born infants ; it is common 
in infancy and childhood. Steffen and Baginsky describe a number 
of cases occurring in infancy. Of 66 cases of pericarditis in chil- 
dren, Baginsky found 20 to occur during the first year of life. The 
next greatest frequency was between the first and the fifth year. 

Etiology. — The majority of cases occur as complications of acute 
articular rheumatism (Steffen, Friedreich, Bauer, Baginsky), with or 
without chorea. Tuberculosis and pleuropneumonia rank next as 
etiological factors. Pericarditis occurs in the exanthemata, scarlet 
fever, measles, and typhoid fever. It may complicate pertussis, 



PERICARDITrS. 459 

diarrhoea] disorders, otitis, meningitis, peritonitis, mediastinals, or 
any septic process, such as osteomyelitis. It is also in the newly 
horn infant concomitant with septic conditions. Finally, trauma- 
tism may cause pericarditis. The tuberculous form is uncommon 
before the fifth year of life (See). 

Bacteriology. — The pyogenic bacteria most frequently found in 
pericardial effusions, and which play an etiological role, are the 
pyogenic streptococci and staphylococci, the pneumococcus of Frankel 
and Weichselbaum, the tubercle bacillus, the Friedliinder bacillus, 
the Bacterium coli, and the Bacillus pyocyaneus (Ernst). 

Forms. — There are the same forms of pericarditis in children as 
in the adult subject. The forms with effusions have, however, a 
tendency to become purulent, especially in infants and younger chil- 
dren (Baginsky). In these patients, the fibrinous forms result in 
localized or general adhesions of the two layers of the pericardium 
and in partial or complete obliteration of the pericardial sac (ad- 
herent pericardium). 

Morbid Anatomy. — In the mildest forms, there is only a loss 
of lustre to the serosa in circumscribed or diffuse areas. The fluid 
in the pericardial sac may be increased in quantity and may contain 
cellular elements. In other forms, the surface of the pericardium is 
coated with a layer of fibrin of greater or less thickness. The fibrin 
may be in the form of bands or of small villous formations. There 
may be minute hemorrhages on the surface (Delafield). In more 
pronounced processes the fibrin is in the form of hemorrhagic tena- 
cious masses forming a thick network of strips or bands (cor 
villosum). The quantity of fluid in the sac varies. The fluid may 
contain blood. 

In the first stage of inflammation, the connective tissue of the 
pericardium is infiltrated with lymphoid cells and the vessels are 
filled with blood. After the third day, new vessels appear in the 
fibrinous exudate on the surface. Fibroblasts, spindle-shaped, 
spherical, and branching, form a network in this new tissue (Ziegler). 
( rranulation tissue and finally new connective tissue replace the fibrin- 
oid exudate, after a period of weeks (productive pericarditis). The 
so-called opaque areas of thickened pericardium, the macula' tendinese 
-cen ill adults, are rare in children (Steffen). Adhesions, either 
localized or general, may form between the two layers of the pericar- 
dia] sac, causing its partial or complete obliteration. 

Tuberculous forms of pericarditis may occur as miliary infiltration 
of the parietal and visceral layers of the pericardium. There may 
be serous, serofibrinous, purulent, or hemorrhagic exudate in the sac, 
or gray cheesy nodules of tubercle tissue may be present in the 
epicardial and subpericardial tissue (Ziegler, Baginsky). 

Myocarditis, circumscribed or general, may occur in all forms of 
pericarditis. The adhesive form- are complicated with myocarditis. 



460 DISEASES OF THE HEART AND PERICARDIUM. 

Symptoms. — Pericarditis in children manifests itself by rational 
symptoms and physical signs. 

Rational Symptoms. — At the bedside, the symptoms of the differ- 
ent forms of pericarditis cannot be divided into classes. Some 
of the fibrinous or dry forms run an insidious course without giving 
any marked symptoms of the disease.- On the other hand, large 
effusions may make their appearance without any previous rational 
symptoms which are characteristic. This is the case in the forms 
of pericarditis in infants and children, which occur in septic con- 
ditions, in pneumonia, empyema, and in the exanthemata. On the 
other hand, if attention has been drawn to the heart, it will be 
found that certain symptoms may be traced to the inflammatory 
process in the pericardium. If the patients have been suffering 
from endocarditis of rheumatic origin, empyema, or one of the exan- 
themata, they show the symptoms of grave cardiac disease. They 
have an anxious facial expression, with marked pallor and cyanosis 
of the lips. They do not, as a rule, complain of pain. The respi- 
rations are markedly increased, as is also the pulse. Older children 
may complain of pain or uneasiness in the epigastrium. They also 
show marked dyspnoea and orthopnoea. In infants there are signs 
of pain on breathing. In some of the fibrinous forms there is fever, 
but dry forms of pericarditis may run their entire course without 
it. The purulent forms give a remittent temperature-curve. The 
pulse is rapid, varying from 120 to 150. In the forms with effusion, 
the pulse is irregular. If myocarditis is present, the pulse is irreg- 
ular and persistently high, and there is an accompanying increase 
in the number of respirations. There is no case on record in which 
the diagnosis of mediastinopericarditis has been made in a child 
during life and confirmed at autopsy, nor does the so-called pulsus 
paradoxus give any assistance, since it is present in other conditions 
in childhood (Steffen). 

Physical Signs. — In pericarditis, there are the physical signs of 
the dry plastic forms and the forms with effusion into the sac. 
The signs of the dry pericarditis and those of the first stage of that 
with effusion are practically identical and may be considered 
together. 

Inspection. — In dry plastic pericarditis and the first stage of 
pericarditis with effusion there may be no signs to be detected by 
inspection. On the other hand, there may be an increased action, 
apparent to the eye, over the whole cardiac area to the left. When 
effusion takes place, little or no pulsation can be made out over 
the cardiac area when the patient is in the recumbent position. 
There may be distinct bulging of the cardiac area, varying with the 
amount of fluid present. No localized apex impulse is visible when 
the amounts of fluid are large. There may instead be a diffuse 
pulsation over the area of the apex and toward the sternum. 



PERICARDITIS. 461 

Palpation. — In dry pericarditis, and in the first stage of peri- 
carditis with effusion, there is a friction fremitus felt over the areas 
in which the friction murmur is heard. This may be at the apex, 
at the base, or along the right ventricle close to the lei't border of the 
sternum. 

The Apex-beat or Impulse, and its Relations to the Chest Wall in 
Pericarditis with Effusion. — As effusion takes place, it is indicated 
by certain physical signs relative to the heart apex, and by the 
line of dulness to the left. Investigations have shown that, when 
the patient is in the recumbent posture, pericardial effusion first 
collects at the base of the heart around the great vessels. It next 
collects over the anterior surface and in the anterior-inferior cul-de- 
sac of the pericardium (Voinitch). When the patient is recumbent 
the effusion does not necessarily push up the apex-beat. On the con- 
trary, it separates the heart from the anterior chest wall. In mod- 
erate effusion the apex-beat may still be felt in the normal position. 
As the effusion increases, the apex-beat recedes and becomes less 
discernible and more diffuse, and in large effusion may disappear. 
This is especially the case, if there is dilatation of the heart or 
adhesions at the apex. When the effusion is again absorbed, the 
apex-beat becomes evident in the former situation. 

When the patient is sitting, the pericardial effusion collects 
beneath and behind the heart, and, if the heart is not enlarged or 
held down by adhesions, the apex-beat may at first be displaced 
upward, and will be felt above and to the outside of its normal 
position. These facts will explain the failure in certain cases of 
pericarditis, to obtain the displacement of the apex -beat upward. 
In one of my cases, a boy of six years, suffering from chorea, 
endocarditis, dilated heart, and pericarditis, the apex-beat was ob- 
served in the beginning of the stage of effusion to be located in 
the sixth space, -lightly outside the nipple line. Effusion having 
occurred, the apex-beat could still be observed in its former locality, 
but the area of absolute dulness indicating effusion extended beyond 
the apex, four cubic centimetres to the left of the mammillary line. 
The effusion disappeared and the apex then corresponded with the 
line of dulness of the left ventricle. 

Percussion. — In dry fibrinous pericarditis, and in the dry stage of 
pericarditis with effusion, there is no increase in the area of cardiac 
dulness directly traceable to the disease. If there is a slight di- 
latation or relaxation of the ventricle due to myocarditic compli- 
cation, the normal precordial dulness may be more distinct. 

The effusion must have a bulk of 40— 60 grammes ( 1 1 to 2 fluid- 
ounce-) before definite signs of its presence can be obtained. 

In children, the area of dulness due to pericardial effusion does not 
have the triangular shape seen in adult-. 'Hie position of the heart 
is more horizontal and its shape is retained by the distended sac 



462 



DISEASES OE THE HEART AND PERICARDIUM. 



Thus, to the left, the dulness may extend in a eurved line outside the 
situation of the nipple. Superiorly, it may extend as high as the first 
rib. It then extends in an almost horizontal line two or more centi- 
metres to the right of the sternum (Fig. 135). The line of dulness 



Fig. 135. 




Pericardial area of dulness due to effusion in boy, six years of age. Chorea, endocar- 
ditis, and pericarditis : x, apex-beat before effusion ; o o o o, friction murmur ; outer curved 
line shows general shape of distended pericardial sac. 

to the right of the sternum then extends downward in an almost 
vertical line to the liver (sixth space) (Steffen, Baginsky, Ausset). 
These facts are very important in differentiating dulness result- 
ing from pericardial effusion from dulness due to other causes. 
Even in moderate effusion there is resistance to the percussing 
finger. If the patient's position is changed from the recumbent 
to the sitting posture, the heart falls forward, the pericardial sac is 
distended, and the dulness to the left may come more toward the 
mammillary line and, to the right, toward the sternum (Bagin- 

sk y)- 

Auscultation. — The friction sound is diagnostic in dry plastic 
pericarditis and in the first stage of pericarditis with effusion. It 
may, at the outset, be heard at the apex (Steffen), but is also heard 
to the left of the sternum over the base, or below, to the left of the 
sternum, over the fourth or fifth space. Steffen finds it in children, 
at first, most frequently at the apex. The murmur may be heard on 



PERICARDITIS. 463 

systole or diastole, or on systole only. It may or may not accom- 
pany the valvular sounds. It is of very limited distribution, is not 
conducted, and is of a tine crepitant quality or has a rubbing or a 
rasping or clicking sound. In the ease of a boy suffering from re- 
current chorea and pericarditis, there was a loud scraping friction at 
the apex with murmurs of mitral and aortic regurgitation. I was 
able in this case to confirm the statement of Walsh, that a loud peri- 
cardial friction may sometimes be heard behind, between the scapulae, 
to the left of the spine. The friction may for the first day or two 
be of a crepitant quality and then acquire a rubbing quality. I 
observed this change in a child four years of age. The patient suf- 
fered from dilatation of the left ventricle with mitral insufficiency and 
stenosis with pericarditis. The friction for two days was crepitant 
in quality and just audible over the fourth and fifth spaces, to 
the left of the left border of the sternum. After two days, the 
murmur of friction acquired a loud rubbing quality. The murmur 
Is sometimes very evanescent or may disappear or reappear at short 
intervals. The sounds may be intensified by causing the patient 
to lean forward. When effusion appears, the friction sounds 
may entirely disappear, or may be heard only in areas around the 
great vessels or indistinctly over the praecordium. A knowledge 
of these facts is important in making a diagnosis of fluid in 
the pericardial sac. The friction sounds may reappear on absorp- 
tion of fluid. Pleuropericardial friction sounds are rough or 
fine sounds obtained in children as in adults with the respiratory 
movements of the lung. They are intensified on expiration and 
disappear when respiration is momentarily suspended. They may 
be heard over any part of ihe praecordium. They are caused by 
the rubbing of the inflamed pleura and pericardium against each 
other. This friction is limited to one edge of the cardiac area, 
generally the left, and is sometimes heard in the back, on the left 
Bide. 

The diagnosis of pericarditis can only be made from the physical 
signs. In dry plastic pericarditis and the first stages of pericarditis 
with effusion, the friction sound is the diagnostic sign. If a peri- 
cardial friction is once obtained, careful watch should be kept for the 
appearance of fluid. It is not possible at the outset to differentiate 
a dry pericarditis which will remain as such, from the first stage of a 
pericarditis with effusion. 

In the stage of effusion, small amount- of fluid will sometimes 
escape diagnosis. This is likely to occur if a process such as 
empyema is in progress on the left side. The firsl stage of a peri- 
carditis may escape diaL r n<»-i< if the friction sound is evanescent. If 
the effusion appears in considerable quantity over the great vessels, 
percussion i- made in this region, especially to the right side of the 
sternum at the level of the second or third space, for an increase in 



464 DISEASES OF THE HEART AND PERICARDIUM. 

dulness due to a distended pericardium. Absence of dulness in this 
region across the sternum and for a few centimetres to the right of 
the right border is presumptive evidence against the presence of any 
considerable effusion. If dulness exists to the right of the sternum, 
low down only on a level of the fourth interspace, there is probably 
no pericardial effusion, but, instead, dilatation of the right ventricle. 

Differential Localization by Percussion of Pleural and Pericardial 
Effusions. — In cases in which pericardial effusion is very large or 
in which there is pleural effusion into the left side of the chest, a 
question may arise as to whether there is a simple pleural effusion 
general or localized, pericardial effusion, or both. Percussion along 
the sternum will in simple left pleural effusion easily mark out the 
displaced left pleural fold. Even if there are large amounts of fluid, 
the fold of the left pleura will be found to be distinctly displaced 
toward the right border of the sternum. The pleural line will 
never, except under very exceptional conditions, pass beyond the 
border of the sternum to the right. If large pericardial effusion is 
present, the dull note of the effusion extends beyond the right border 
of the sternum. In left pleuritic effusion the apex of the heart is 
found by auscultation to be distinctly displaced to a situation 
beneath the sternum, while in pericarditis it will at first be found 
to be in the normal position and subsequently to disappear or to be 
displaced upward and outward. 

The prognosis of rheumatic pericarditis is good. The purulent 
forms of pericarditis are in the great majority of cases fatal, espe- 
cially in very young infants. In older children, I have seen cases 
of purulent pericarditis, due to infection from a concurrent pneumonia 
or empyema, recover with timely pericardotomy. The septic forms 
of purulent pericarditis, complicating sepsis of the newly born and 
forms of osteomyelitis, are fatal. 

The treatment of the dry fibrinous forms of pericarditis is limited 
to the relief of the pain and the treatment of the primary condition, 
rheumatism. The pain is best relieved by the administration of 
mild opiates. Codeine in small doses is efficient in many cases. I 
am not in favor of blistering the precordial region in children, or 
of applying a seton, as is done in adults. If the heart is tumult- 
uous, small doses of digitalis in the tincture form and the constant 
application of an ice-bag over the precordial region are the most 
effective remedies. Some authors believe that the ice-bag is also a 
very powerful means of limiting the inflammation. In rheumatic 
or choreic cases the salicylate of sodium is given, or if this disagrees 
with the patient, the ordinary bicarbonate of sodium in doses of 
grains x (6.5) three or four times daily. Perfect rest in bed, long 
after the process has run its course, is indicated, on account of the ill 
effects of strain on the heart after the myocarditic changes which 
are undoubtedly present in many of the cases. 



ADHERENT PERICARDIUM. 465 

When effusioo lias taken place, the question of the advisability 
of puncturing and exploring the pericardium always arises. It is 
very difficult to choose the proper time for entering the pericardium. 
I have had a Dumber of cases of pericarditis with effusion recover 
without being subjected to what is at best a hazardous procedure. I 
can only detail my own practice in these eases. I temporize until 
the orthopnea and cyanosis are extreme and evidences of pressure 
arc marked. Too much importance should not he attached to ordi- 
nary symptoms. On the other hand, if the temperature is high and 
daily remits to near the normal, there may he a purulent effusion. 
If after a reasonable length of time the patient steadily loses ground 
and the signs of effusion are marked, the pericardium should be 
entered to determine the character of the exudate. If it is serous, 
ordinary aspiration will suffice, but if purulent, the operation of peri- 
cardotomy should be performed. Pericardial puncture or incision is 
performed in the same manner as in adults. 

It may be remarked that Henoch has never punctured the peri- 
cardium. In one of his cases, post-mortem examination showed 
small sacculated purulent collections of fluid which could hardly have 
been evacuated by a single puncture. I found a similar condition 
post mortem in a case in which puncture of the pericardium was 
undertaken, and resulted in puncture of the heart. 



ADHERENT PERICARDIUM. 

Adherent pericardium is an agglutination, localized or complete, 
of the visceral and parietal walls of the pericardial sac which becomes 
partly or completely obliterated. The condition follows either a dry 
plastic pericarditis or a pericarditis with effusion, in the stage of 
absorption. In the latter case, if the absorption of fluid has been 
observed and the redux friction-sound obtained, adhesion of the peri- 
cardium may be suspected from certain signs; otherwise, diagnosis 
even within probable limits would in many case- be an impossibility. 
Infant- and children who have withstood an attack of pericarditis, 
especially of the rheumatic form, are very prone to contract this form 
of pericarditis. In most cases it cause- myocarditis of a progressive 
type; hence the importance of understanding the condition. Hyper- 
trophy of the heart, atrophy of the heart, or dilatation of that organ 
may accompany adherence of the pericardium. 

The symptoms, especially in the rheumatic cases, develop late in 
the disease when myocarditis supervenes. The condition may prove 
fatal by progressive affection of the cardiac muscle. One of my 

8, of rheumatic origin, showed post mortem no valvular Lesion, 
There were complete obliteration of the sac and extreme dilatation. 
The symptoms are at first negative. There may be a friction sound 



466 DISEASES OF THE HEART AND PERICARDIUM. 

or a roughening of the cardiac sounds at the base. There is in some 
cases a drawing inward of the apex area of the chest at the xiphoid 
cartilage. A wave-like undulation of the cardiac area with an increase 
of cardiac dulness is sometimes found. There may be persistent 
asystole not controllable by digitalis (See). In my cases there were 
angina, a persistently high pulse with an increase in the number of 
respirations, and in the last stages, all the symptoms of non-compen- 
satory dilatation of the ventricle which are seen in valvular disease. 
There may be a mitral systolic murmur simulating that seen in val- 
vular disease. In spite of all these symptoms, it is rarely possible to 
make a positive diagnosis during life. 



HYPERTROPHY AND DILATATION. 

Cardiac hypertrophy and dilatation, combined or singly, and with- 
out any valvular lesion, occur in isolated cases in childhood. The 
condition is rare before the fifth year. A number of cases occurring 
between the fifth and the tenth year have been reported. If hyper- 
trophy alone is present, it may affect the left ventricle only, or both 
ventricles. Dilatation usually affects first the right ventricle and 
then the left. The condition develops as a result of toxsemic influ- 
ences, in the acute infectious diseases, such as scarlet fever, pneumonia, 
diphtheria, and typhoid fever. 

Hypertrophy with or without dilatation is one of the sequela? of 
acute or chronic nephritis. The nephritis complicating scarlet fever 
is frequently the cause of cardiac hypertrophy with or without dila- 
tation. Atheromatous conditions of the arterial system with dimi- 
nution of the calibre of the aorta may cause hypertrophy with or 
without dilatation. Acute dilatation as a result of heart strain is 
unknown in children. 

The Symptoms are not characteristic. In the absence of all 
other heart lesions, the diagnosis of cardiac hypertrophy or dila- 
tation is made from the physical signs. These do not differ from 
those found in the adult subject. The rational symptoms also resemble 
those of the adult. In dilatation of the heart, there are the irregu- 
lar heart action, the dyspnoea or orthopnoea, the pallor of the surface, 
cyanosis, and in the later stages swelling of the liver and spleen. 
Transudates in the pleural and abdominal cavities are apt to occur 
toward the close. Sudden death has occurred in some cases of dila- 
tation of the acute variety. In hypertrophy, the symptoms closely 
resemble those just detailed. At the bedside, the diagnosis of hyper- 
trophy, of dilatation, or of both, must of necessity rest on the physical 
signs. 

The treatment varies with the nature of the primary disease 
(nephritis or toxaemia) present. The nephritis should be treated 



HYPERTROPHY AXD DILATATION. 467 

and the heart will take care of itself. If there is an infectious dis- 
ease, sueh as typhoid fever, diphtheria, or scarlet fever, both the 
heart and the primary affection should be treated. 

Leading A.uthorities Referred to in Chapter VII. 

Ausset, V.. : Maladies des Enfants, 1898. 

ffleischman, L. : Klinik der Piidiatrik. 1ST"). 
QuUnunm, P.: Untersuchungs Methoden, 1886. 
Henschen, S. E. : Ac. Herzdilatation, Jena, 1899. 

Heubner, O. : " Leber Chorea." Verhandl. d. ijesellschaft der Kinderiizte, Ham- 
buig, 1901. 

Hoehsinger, Carl: Auscultation des Kindlichen Herzens, Wien, 1890. 

sen, T. : "Endocarditis,'' Nothnagel's Spec. Path., 1900. 
Jueobi, A.: "Functional and Organic Heart Murmurs," Med. News, 1900. 
: "Acute Rheumatism in Infancy and Childhood," Amer. Clin. Lectures, 

Keating and Edwards: " Tlie Pulse in Childhood," Archives of Pediatrics, 1888. 
Musser, J. H. : " On the Disappearance of Endocardial Murmurs,'' Brit. Med. 
Jour., 1897. 

Mendolsohn, M: "Der Einfluss des Radfahreus, Berlin. 1896. 

Packard, E. A. : N. Y. Med. Jour., June, 1899. 

Sahli, H. : Topographische Percussion, Bern, 1882. 

Soltmann: Herzgerausche im Kinderalter. 14te Verhandl. gesell. Kinderiizte, 

Sansom, A. E. : Diagnosis of Diseases of the Heart, London, 1892. 
Ullman,./.: 'The Tonsils as Portals of Infection, with Literature," Medical 

1900. 
VierorJt. H. : "Die Augeborenen Herzkrankheiten,'' Nothnagel's Spec. Path.., 
etc., 1898. 

Walshe: Diseases of the Heart, Loudon, 1873. 

Weill, E. : Maladies du Ooeur des Enfants, Paris, 1895. 



CHAPTER VIII. 

DISEASES OF THE NERVOUS SYSTEM. 
METHODS OF DIAGNOSIS. 

Lumbar Puncture. 

Lumbar puncture was first practised by Quincke. It is to-day 
one of the most useful adjuncts to the methods of diagnosis in acute 
and chronic forms of cerebral and spinal disease. Its future useful- 
ness as a therapeutic measure is not clearly established, but will 
probably lie in relieving symptoms due to pressure, and removing the 
excess of inflammatory exudate in the various forms of meningitis. 

The Normal Cerebrospinal Fluid. 

Normal cerebrospinal fluid is a clear colorless fluid having a 
slightly alkaline or neutral reaction. Its specific gravity varies from 
1007 to 1009. It contains from 0.05 to 0.1 per cent, of albumin 
(Quincke, Rieken, Pfaundler), and because of the presence of sugar 
has a slightly reducing action cm copper. It does not coagulate spon- 
taneously. If centrifuged, a microscopic sediment of a few endo- 
thelial cells and leucocytes may be obtained. The cerebrospinal fluid 
is normally under a pressure of from 5 to 35 millimetres of mercury. 
The pressure in infants is lower than that in children. The causes 
of the variations of pressure and the nature of the conditions under 
which they occur have not as yet been determined. Respiration 
causes a deviation of fully 6 millimetres of mercury in the manom- 
eter column. 

Abnormal Conditions. — The cerebrospinal fluid will in patho- 
logical states vary in respect to specific gravity, composition, appear- 
ance, and in the amount of sediment contained. The pressure in the 
subarachnoid and cerebrospinal spaces will also vary in different 
forms of disease. 

The specific gravity in tuberculous meningitis varies from 1003 to 
1011 (Lenhartz), in cerebrospinal meningitis from 1005 to 1012 
(Pfaundler). 

The gross appearances of the fluid obtained by lumbar puncture 
may be changed by the admixture of blood. Blood may come from 
the puncture wound or may have been in the canal previous to 
puncture as a result of a hemorrhagic pachymeningitis or of some 
form of cerebrospinal meningitis, traumatism, or apoplexy with 

468 



THE ABNORMAL CEREBROSPINAL FLUID. 469 



rapture into the ventricles. The wounding of veins either in the 
tissues or in the cauda equina may cause the admixture of blood. 
The quantity of blood may he just sufficient to tinge the fluid or 
the blood may be almost pure. It is not possible to determine 
whether the admixture of blood is or is not the result of accidental 
puncture of a vessel unless, as in pachymeningitis or traumatism, 
light is thrown on the matter by the history of the case and the 
presence of blood on repeated puncture. The accidental admixture 
of blood is unfortunate, since it obscures the microscopical diagnosis. 
The hemorrhage into the spinal canal is never alarming or of serious 
import. 

Tuberculous meningitis changes the gross appearance of the fluid 
obtained by lumbar puncture. The fluid may be quite clear, excep- 
tionally cloudy, opalescent, or in rare cases purulent. As a rule, 
however, it is clear in the early stages of the disease and cloudy in 
the later period. W the test-tube is held in a strong light, there 
may be ^een, in a clear or cloudy fluid, myriads of highly refracting 
particles resembling the motes in a sunbeam (Moser, Bernheim, 
Pfaundler). The appearance is quite characteristic. It was first 
explained by Lichtheim, as the result of spontaneous coagulation. 
If a test-tube of the fluid obtained by lumbar puncture is placed in 
the upright position in an ice-box, there is found after twenty-four 
hours, a fully formed cobweb-like, funnel-shaped coagulum, beginning 
a little below the surface of the fluid and extending downward, the 
broader part of the funnel being above. According to Pfaundler, 
this coagulum is of diagnostic import. I have relied on its appear- 
ance in fluid which was not contaminated with blood, and found it 
of great value. The formation of the coagulum begins after the fluid 
ha- stood for two hours, and is fully completed by the following day. 
It is usually found from eight to twelve days before death. 

Suppurative Meningitis. — In this form of meningitis, the fluid 
obtained by lumbar puncture is purulent, opalescent, grayish-white, 
grayish-yellow, or brownish (hemorrhagic). Exceptional cases give 
a clear fluid. There may be a spontaneous coagulum resembling 
that -ecu in tuberculous meningitis. 

Epidemic and Sporadic Cerebrospinal Meningitis. — In the early 
stage of this disease, the fluid may be quite clear with suspended 
microscopic sediment. It may also be cloudy or thick, creamy or 
bloody. It may at first be clear, and later in the disease become 
purulent (Councilman). 

Chronic Hydrocephalus. — This give- a clear fluid with no sus- 
pended particle- visible to the eye, although microsoopially there may 
be leucocytes. Pfaundler in one of hie cases obtained a fluid which 
was cloudy because of the admixture of leucocytes. 

Tumor of the brain give- a clear Huid. I have had a case of 
this kind. 



470 DISEASES OF THE NERVOUS SYSTEM. 

Sediment. — This feature will be fully discussed under the sections 
devoted to Tuberculous Meningitis and Cerebrospinal Meningitis. 

The pressure uuder which the cerebrospinal fluid is retained in 
the subarachnoid space and in the spinal canal is increased in the 
various forms of meningitis. This is especially true of tuberculous 
meningitis, in which the pressure may reach 110 m.m. of mer- 
cury. In this disease the pressure increases from the initial period 
to that of pressure symptoms, and diminishes toward the close of 
the disease — the stage of paralysis. Ventricular involvement gives 
the highest pressure figures. The following figures are taken from 
Pfaundler' s tables : 

First stage 48 m.m. of mercury. 

Stage of pressure 52 m.m. " " 



Stage of paralysis 24 



m.m. 



it 



In suppurative meningitis, the pressure varies from 10 to 37 m.m. 
of mercury ; in cerebrospinal meningitis, from 24 to 50 m.m. ; in 
hydrocephalus, from 6 to 60 m.m. ; in tumor of the brain, from 3 
to 52 m.m. (Quincke, Slawyk, Pfaundler). 

The presence of an increased amount of albumin in pathological 
states has been noted by Wentworth, Quincke, and Pfaundler. In 
tuberculous meningitis it may reach 0.3 per cent. ; in purulent menin- 
gitis, 0.6 per cent. 

The Operation of Lumbar Puncture. 

The instrument consists of a trocar and canula such as is em- 
ployed in tapping cavities. The best form of instrument has a han- 
dle sufficiently large to be grasped firmly (Fig. 136). The canula 
should be at least one millimetre in diameter. It is not necessary to 
use a manometer. In infants, the tenseness of the fontanelle is a 
rough guide in estimating the pressure in the subarachnoid space. 

Place of Puncture. — The puncture is made in the space between 
the third and fourth or the fourth and fifth lumbar vertebrae. This 
point is obtained by palpating the crests of the ilium ; an imaginary 
tangent to these crests strikes the fourth space. The space above 
this imaginary line will, as a rule, be found to be the third space. 
Puncturing the canal in the space between the sacrum and coccyx 
or in the lower sacral space offers no advantages either anatomically 
or from a diagnostic standpoint. 

Method. — Local anaesthesia only is necessary. The back of 
the patient is carefully scrubbed with green soap, then washed 
with alcohol and ether, and finally with sublimate. The patient 
is laid on either side according to the convenience of the operator. 
The spine is curved so that the spinous processes may be distinctly 
seen and palpated (Plate XVIII. ). No considerable pressure should 



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CD r 



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THE OPERATION OF LUMBAR PUNCTURE. 



471 



Fig. 136. 



he brought to hear on the neck, since in cerebrospinal meningitis 
or in the basilar form of meningitis in which there is opisthotonos, 
serious injury to the neck mav be caused. The spine is curved 
from the shoulders and pelvis. The needle, having been previously 
boiled, is introduced in the median line between the spinous 
processes and is directed upward (Plate XIX.). When it is in 
the canal, it is perceived that there is a lack of 
resistance, and that the point of the instrument is 
tree. The canula is withdrawn and the first drops 
caught in a sterilized test-tube. A second test-tube 
i- substituted for the first after a few drops of 
bloody fluid have been allowed to flow out, and 
from 10 to 50 c.c. of fluid are withdrawn, the 
amount varying with the pressure. If it flows 
drop by drop, 20 c.c. are sufficient for diagnostic 
purposes and also to relieve the pressure. If there 
is opisthotonos and the fluid does not flow well 
at first, cautious straightening of the neck will 
facilitate the outflow. In infants, the fontanelle 
i- a good guide in gauging the pressure. As soon as 
a few cubic centimetres of fluid have been withdrawn, 
the fontanelle will be felt to be considerably flattened 
and relaxed or even depressed. Heubner has with- 
drawn 100 c.c, but the removal of such large 
quantities is unnecessary and may be followed by 
hyperpyrexia and collapse. I rarely withdraw more 
than '20 e.c. If there is a dry tap, the canula 
should be withdrawn and a second attempt made on 
the following day. A dry tap may be caused by a 
fibrin clot or by the falling of the Cauda equina in 
front of the opening of the canula. The fluid may 
be viscid and refuse to flow. In that case the fluid 
should not be aspirated with a syringe, since in the experimental 
laboratory this method ha- been proved to be hazardous. If car- 
ried out as above directed, I have never Been any ill results from 
the operation of lumbar puncture. After puncture, the canula 
i- rapidly withdrawn and the wound dressed with iodoformized 
gauze. 

Indications for Lumbar Puncture. — Lumbar puncture is per- 
formed in the various forms of meningitis for diagnostic purposes, 
to determine the character of the fluid. It is not always an easy 
task to decide whether it should be resorted to. The decision 
is especially difficult in private practice, where the procedure is 
regarded with dread. Any marked disease of the lungs should 
first be excluded. In many cases of pneumonia the cerebral symp- 
toms are marked. Only very marked symptoms of cerebral press- 




Trocar and canula 

for performing lum- 
bar puncture. 



472 DISEASES OF THE NERVOUS SYSTEM. 

lire and the suspicion of pnenmococcus meningitis should cause the 
physician to resort to puncture in order to fix the diagnosis. It 
is best not to perform it while the lesion in the lung is markedly 
active. Cases of tumor of the brain should not be subjected to 
puncture. 

Indefinite cerebral symptoms, such as headache, restlessness, and 
convulsions of a general character, are not indications for puncture. 
I have seen cases of meningitis of the cerebrospinal type which gave 
few symptoms of disease, there being indefinite sopor, general mus- 
cular weakness with delayed reflex at the knee and marked emacia- 
tion, but no marked rigidity of the neck. 

In doubtful cases I refrain from puncture. Cases with meningeal 
symptoms, in which there is a history of a blow, are proper subjects 
for puncture, since it is necessary to differentiate between menin- 
gitis, and abscess of the brain. In the various forms of purulent 
meningitis, symptoms of pressure such as convulsions, and signs of 
suppuration such as chills, are indications for puncture. After the 
first puncture is made and the diagnosis fixed, I do not in tuberculous 
meningitis repeat the operation. 

The indications for puncture in other diseases such as hydroceph- 
alus will be discussed under the headings of the various affections. 



INFANTILE CONVULSIONS. 

(Eclampsia.) 

Convulsions are a series of violent clonic contractions of a 
number of muscles or of the muscles supplying one limb. There 
is always more or less tonic spasm. The convulsions are paroxysmal, 
and are accompanied by loss of consciousness. In this section, 
only the acute convulsions of infancy and childhood will be con- 
sidered. They should be sharply differentiated from certain affections, 
such as laryngismus, tetany, or epilepsy accompanied by spasms, 
although all these are classed as forms of convulsion. The acute 
convulsions of infancy and childhood are acute symptomatic phe- 
nomena. They occur chiefly during the first half-year of life. 
Fully four-fifths of the cases occur before the end of the second 
year (Kassowitz). They are uncommon after this period, but a child 
that has had convulsions in infancy is likely to have them on the 
slightest provocation up to the fifth year. 

The pathogeny of convulsions in infancy and childhood is the 
same as in the adult. The explosions are due to irritation of the 
centres in the ponto-bulbar junction or in the area of Rolando 
(Hughlings Jackson). The starting-point of every convulsion is the 
ganglion cell (Peterson). The peculiar constitution and unstable state 
of the nervous system in childhood make children particularly sus- 



INFANTILE VOSVULSIOSS. 473 



ceptible to the action of the agents (toxins) which incite convulsions. 
It is not known whether inherited neurotic tendencies are powerful 
at this early period, or whether alcoholism or epilepsy in the family 
really influences the occurrence of purely acute convulsions. Rachitic 
children are particularly subject to convulsions, because the cranial 
hones are the seat of hyperemia and softening (Kassowitz, Elsasser). 
The motor areas of the brain are supposed to be in a state of constant 
irritability. 

The etiology of acute convulsions is very diverse. The majority 
of the convulsive seizures of infancy and childhood occur in connec- 
tion with the infectious diseases, and at the onset of those affections. 
The explosion appears to be caused by the initial effect of the 
toxaemia and temperature reaction on the ganglion cell. Any infec- 
tious disease, such as acute amygdalitis, the exanthemata, influenza, 
pertussis, mumps, may be ushered in with a convulsion. Convulsions 
sometimes take the place of an initial chill in pneumonia and in 
malarial fever. Any infection from the gut, such as those due to 
indiscretions in diet, and ^astro-enteric disease of any kind, may 
cause a convulsion. Children who eat an excessive quantity of 
meat are particularly subject to these seizures. Poisons circulating 
in the blood or a traumatism caused by a fall on the head are apt to 
cause convulsions in susceptible children ; ursemia frequently causes 
convulsive seizures. In acute or chronic nephritis, the urine should 
always be tested. Dentition is frequently mentioned among the 
causes of convulsions. Since dentition in a normal infant is devoid 
of' symptoms, it is stretching theory to ascribe infantile convulsions 
to irritation of the trigeminal branches. The acceptation of this 
theory might cause some serious condition, of which the first indica- 
tion is an eclamptic seizure to be overlooked. A severe hemorrhage 
causing an acute cerebral ansemia may give rise to a convulsion, as 
may also morbid growths of the brain or cord. Convulsions of the 
latter form are hardly to be included in the practitioner's conception, 
of infantile convulsions of the acute type. 

Morbid Anatomy. — Kussmaul and Tenner have demonstrated 
that there is an acute anaemia of the brain during convulsions. On 
the Other hand, it often happens that the convulsion is the cause of 

the bursting of a cerebral vessel. En such cases, the signs of cerebral 
surface hemorrhage .ire present at autopsy. In other cases, although 
death has occurred during a convulsion, nothing is found post 
mortem but an oedema of the brain substance, of doubtful origin. 

Symptoms. — The majority of convulsive seizures in infants and 
children are single. In certain cases the convulsions are repeated and 
extend over a prolonged period. The latter are not cases of simple 
acute infantile convulsions. The Bymptoms of acute eclampsia are 
sometimes so very slighl a- to be scarcely noticeable. Only a very 
observant mother will see a slighl twitching of the lips and eyelids, a 



474 DISEASES OF THE NERVOUS SYSTEM. 

momentary turning of the eye and cessation of breathing, or a momen- 
tary spasm of the whole trunk. The expression " internal convulsion," 
so frequently heard, evidently denotes these slight eclamptic seizures. 
The genuine convulsion comes on without premonitory symptoms. 
There is a momentary tonic spasm of the body, the head turns to 
one side and upward, and there is a corresponding upward direction 
of the eye. Then follows a series of clonic spasms involving the 
upper and lower extremities, and lasting for some time. The patient 
froths at the mouth, the tongue is sometimes protruded and bitten, 
and there is involuntary passage of feces and urine. The whole 
paroxysm may last from half a minute to three minutes. The patient 
then passes into a stuporous condition or into sleep. During the 
spasm, the jaws are set and there is grinding of the teeth. There is 
cyanosis, on account of the spasm of the respiratory muscles and the 
interference with respiration. Not all convulsions end with the 
first paroxysm, although this is so in the great majority of cases. 
In cases in which the organism is peculiarly susceptible one paroxysm 
may succeed another rapidly. The child may be in a state of 
eclampsia for an hour, after which it may pass into the comatose 
state. The coma may be momentary or may merge into a sleep of 
variable duration. The end of the convulsive spasm is signalized 
by muscular clonic spasms decreasing in severity, until finally a long- 
drawn inspiration ends the attack. 

Diagnosis. — It is very important to be able to distinguish be- 
tween the various forms of convulsive seizures. Those occurring 
immediately after or within a few hours or days of birth have a 
different etiology from those just described. They may be caused 
by cerebral hemorrhage, and there will be symptoms after the con- 
vulsions, such as palsies, contracture, difficulty ■ in deglutition, and 
prolonged coma. In these cases the convulsions are repeated. Ate- 
lectasis of the congenital variety may cause convulsions. The 
patients have slight or marked cyanosis, and, in the intervals, increase 
of respirations and signs of bronchitis and collapse of the lung. 

Tumor and abscess of the brain, and meningitis, both cerebro- 
spinal and tuberculous, may be ushered in by convulsions. In tumor, 
the convulsions are limited to the area in which the tumor or abscess 
is localized. In forms of meningitis, there will be the symptoms of 
that disease. Drugs and poisons may give rise to convulsions. The 
history of such cases will be of service. Cases of tetany and tetanus 
have convulsions in the course of the disease. In tetany there may 
be several convulsions in the course of twenty-four hours. Tonic 
spasm is the chief feature of the convulsion in tetany and tetanus. 
The clonic form distinguishes acute convulsions. In tetanus there is 
slowly increasing opisthotonos. In tetany the body may be lax in 
the interval, but there are rare cases of tetany which resemble 
tetanus in that there is rigidity in the intervals between the 



FXFA X 77 L E t <0 XVI TLSIONS, 475 

spasms. In tetany the extremities have a characteristic position. 
In some eases of simple acute infantile convulsions, an increased 
irritability of the oerves and muscles to mechanical stimulus re- 
mains for days after the paroxysms. The Chvostek and Trous- 
seau phenomena are found. Some authors have regarded these 
cases as cases of latent tetany. The diagnosis of the various epi- 
leptiform seizures will be considered in the section devoted to that 
subject. 

The prognosis of acute infantile convulsions is generally good, 
but sine;' death has occurred in these seizures, as well as cerebral 
hemorrhage, caution should always be exercised in predicting the 
immediate outcome. The patient having been once tided over the 
initial paroxysm, it may be confidently expected that it will not be 
repeated. In the presence of fever, it cannot be predicted what 
affection may follow the seizure. Primary seizures should not be 
regarded as forerunners of epilepsy. Many infants and children 
affected with convulsive seizures pas> through later life without 
any sign of that disease. 

Treatment. — The seizure i> frequently over before the physician 
arrive-. If such is the case and the infant is in the stage of stupor, 
it should not be disturbed unless there is high fever or a history 
of the patient's having eaten some irritating substance. It often 
happens that the paroxysm supervenes in the presence of the physi- 
cian. The patient is placed on a bed, the clothes loosened, and 
a small object, such a- the handle of a tooth-brush, placed between 
the teeth to save the tongue from injury. Nothing further is needed. 
The paroxysm is as a rule over in three minutes at most. If it 
persists or i- immediately succeeded by another, the patient is 
placed in a warm bath, after which a few drops of chloroform are 
administered by inhalation to control the convulsions. A high 
rectal enema of the temperature of 110° F. (43.3° C.) is at once 
administered. I have in some cases continued the administration of 
chloroform for fully an hour. Caution should be exercised in its 
administration. If, after the seizure, the temperature is high, it is 
treated a- indicated in the section on Infection- Diseases. Unless 
there is some contraindication, a lull dose of calomel i- administered 
a- a routine procedure even if an enema has been resorted to. 
Should the child be restless, it i- well after the convulsion to admin- 
ister a dose of bromide of potassium in combination with chloral, 
either by month or rectum. In repeated convulsions the adminis- 
tration ot* these drugs during the seizures la of inestimable value. 

For several year- past I have used the postural treatment in 
primary convulsive seizures. The patient i< placed with the head 
low, the buttocks raised, and the clothes loosened. I think that the 
paroxysms have been shortened by this treatment. It was suggested 



476 DISEASES OF THE NERVOUS SYSTEM. 

by the theory that cerebral anaemia is the cause of the initial 
paroxysm. I have carried out this postural treatment without any 
ill after effects, such as hemorrhage. In a large number of cases of 
repeated convulsions, the postural treatment should be supplemented 
bv chloroform inhalations. 



HYSTERIA. 

Hysteria is a morbid state of the nervous system in which the 
primary derangement is in the higher cerebral centres. The lower 
centres of the brain, the spinal cord, and the sympathetic system may 
be secondarily disordered (Gowers). It is not a true disorder of 
childhood. Sixteen per cent, of all the cases of hysteria occur in 
youth (Steiner). 

Etiology. — Hysteria is rarer in children than in adults, is more 
frequent in the female sex, and is more often seen in boys than in men. 
According to Briquet and Landouzy, 8 per cent, of all the cases occur 
in the first decade of life, and 50 per cent, in the second. The cases 
of the first decade, according to Barlow, generally develop at the age 
of six years. Cases are occasionally seen in patients of the age of 
three years. Heredity plays an important etiological role. Moral 
and mental influences predispose to development of the condition. 
Children of emotional antecedents are apt to be subject to the disease. 
Sexual disturbances or excesses (as masturbation in boys) are exciting 
causes. Abnormalities of the sexual organs, phimosis, and hypos- 
padias, are apt to excite masturbation and resultant hysteria. In 
some subjects, any acute disease, such as pneumonia or typhoid 
fever, will develop latent tendencies to hysteria. Diphtheritic paral- 
ysis may eventuate in hysterical palsy (Gowers). 

Symptoms. — The disease shows many variations and most 
diverse symptoms. The symptoms may be divided into psychic, 
motor, and sensory manifestations ; or into the convulsive and non- 
convulsive forms of hysteria. 

Pyschic or Mental Hysteria (Non-convulsive). — In most cases 
of this class, the patients suffer from some mental strain. The 
attack begins with a paroxysm of crying or of laughing. The child 
then passes into a violent condition, striking at persons and tearing 
the clothes from its body. I saw a case of this kind in a boy eight 
years of age. He was very bright at school, but shunned the 
companionship of other boys. He masturbated. At times he was 
of a very loving disposition, at other times would refuse to do 
as he was told. The rebellion would terminate in a paroxysm of 
crying, followed by one of shrieking. The boy would tear his 
clothes and then calm down quite exhausted. Girls after undergoing 
some mental strain, such as is incident to a school examination, 



HYSTERIA. 477 

become irritable, morose, and suffer from insomnia. They have laugh- 
ing and crying -pells and refuse nourishment. After a period of 
these symptoms they either recover or pass into a state resembling 
acute mania. Such children are nervous and are born of neurotic 
parent-. 

Bystero-epilepsy, catalepsy, or trance symptoms may manifest 
themselves. These cases are rare in children, but Sachs and Steiner 
have seen them in children of mentally degenerate families. 

Insanity, alcoholism, and chorea in the family predispose to the 
development of hysteria. These cases must be differentiated from 
those of true epilepsy. 

Motor Manifestations (^Convulsive Forms). — These occur in the 
form of bystero-epileptic attacks. After some mental excitement, 
a paroxysm beginning with a shriek will supervene, the sounds 
simulating a bark or a snapping sound. Contortions then supervene 
and the back is arched, as shown in Richer's drawings. During the 
attack, which may last for several minutes, there may be no evidence 
of consciousness. There may be a number of such attacks in the 
course of twenty-four hours. The patient may suddenly fall down and 
have contortions, and the attack may terminate in a crying spell. 
The patients sometimes tear their clothing and become violent. 
These convulsions are differentiated from true epilepsy in that there 
is no aura ; they are preceded by emotional excitement. The onset 
is gradual and the patients emit noises of various kinds during the 
attack. The pupils are normal. There are ecstasy, extravagant 
movements, and tonic rigidity. The vesical and rectal reflexes are 
normal. The patients do not bite the tongue, and rarely injure 
themselves ; the loss of consciousness is temporary or imperfect. 
There are in hysteria irregular twitchings of the extremities and a 
repetition of one specific movement, such as retraction of the head. 
The -pell or paroxysm ends in a crying or laughing fit, or the 
patient- become melancholic. 

Am<»ng the manifestations of hysteria in children is the so- 
called hysterica] stricture of the oesophagus, or globus hystericus. 
There may be spasm of the bladder, hiccough, and loss of voice. 
Hie hitter is common among young girls. I have seen the 
children recover their voice under hypnotic suggestion. Hysterical 
children may, even at the early age of five year.-, pass under hypnotic 
suggestion, into a trance-like state. Whether diarrhoea can be caused 
by hysteria is in my opinion doubtful. I have seen true toxic 
diarrhoea in neurotic children diagnosed as nervous or hysterical. 
One case occurred in a boy of six years. Souk 1 young girls have 
attacks in which all varieties of poses are assumed in the nude state. 
I have seen such a case in a highly intelligent girl of nine year-. 
During the morning bath, the child had a de-ire to assume the most 
grotesque DOG 



478 DISEASES OF THE NERVOUS SYSTEM. 

The so-called epidemics of chorea are now known to be simple 
hysteria. Among these are to be classed the school epidemics and 
the dancing mania of the Middle Ages. 

There may not only be convulsive movements, but also absolute 
paralysis of single muscles or of a group of muscles. Hysterical 
paralyses as a rule follow no anatomical distribution. They are dis- 
tinguished from true palsies by the lack of change in the electrical 
reactions and in the condition of the deep reflexes. The sphincters 
are normal. Paralyses, such as those due to neuritis or poliomyelitis, 
may supervene in a hysterical subject. 

The disturbances of sensation include hyperesthesias and anes- 
thesias. These do not differ essentially from similar conditions in 
the adult subject. There may be hyperesthesia in the region of the 
ovary, or in the skin over the vertebral column. Areas of irritation 
may cause paroxysms. There are hysterogenic zones which are not 
hyperesthetic (Sachs). Anesthesia, partial or general, is more 
frequent. There may be absolute anesthesia to all sensation. There 
may be blindness in one eye or hemianopsia, deafness, or loss of 
taste or of smell. Vision may be affected as above described, or 
there may be photophobia and diminution of visual perception ; the 
retina may be insensible to light, and there may be limitation of the 
field of vision or temporary bilateral loss of sight. 

There are in children cases of anorexia which supervene with 
vomiting after some nervous strain. I have seen this occur in chil- 
dren who were beginning some course of study. In one case it came 
on in the morning just before the child started for school. With 
suspension of school duties, the vomiting ceased. The so-called phan- 
tom abdominal tumor seen in rare instances among children may be 
traced to a hysterical cause. In very young girls I have frequently 
seen forms of palpitation with cardiac anguish which seemed to be 
hysterical. Steiner describes these forms of tachycardia. In these 
cases there is not only absence of cardiac lesion and signs of Base- 
dow's disease, but spinal hyperesthesia may be elicited. 

Diagnosis. — Sensitiveness to pressure over the vertebral column 
is one of the most frequent stigmata of infantile hysteria (Steiner). 
Epigastric tenderness is less frequent than among adults. Hyper- 
esthesia is less marked in childhood than later in life, but is more 
common than anesthesia. Jolly says that deep analgesia is rare. 
Of especial interest in its relation to diagnosis is the fact, that ocular 
symptoms, such as diplopia, may be present morning and evening. 
Paralysis may appear and disappear. There are forms in which 
there may be tachycardia or bradycardia, but during excitement the 
rhythm of the heart may be normal. Cases have been described in 
which the headaches, ptosis, and facial palsies simulate the symp- 
toms of tuberculous meningitis. Study alone will clear up such 
obscure cases. 



TETANY. 479 

Duration and Course. — The symptoms of hysteria are not neces- 
sarily permanent, but are likely to recur alter excitement or nervous 
strain of any kind. 

The treatment of hysteria in children i> based on the same gen- 
eral principles as in the adult. The child is, if possible, removed 
from exciting surroundings. Studies are regulated and bad habits, 
such as masturbation, are, if possible, corrected. The effect of good 
food and outdoor life is marked. Hydrotherapy and massage achieve 
their greatest triumph in this affection. 



TETANY. 

( Teta n ilia ; A rth rogryposis. ) 

Tetany is an intermittent or persistent, more or less painful, tonic 
spasm of groups of muscles of the upper and lower extremities. 

Forms and Frequency. — John Clark in 1815 described this 
disease in children. Trousseau, Baginsky, Chvostek, Erb, Escherich, 
and Ganghofher have completed its symptomatology. In children 
it is most common from the fourth to the twentieth month. There 
are two distinct forms. In the first, the contractures are intermit- 
tent, and come on at intervals, the patients being free from muscular 
spasm in the intervals. The second form, now accepted by the ma- 
jority of writers as the same affection as the former, is that in which 
the contractures are persistent. 

The etiology of this affection is still very obscure. It occurs 
most frequently in the winter and early spring. In my experience 
in an ambulatory clinic, it was customary to see these eases appear in 
groups in the early spring months. The affection is seen under the 
most diverse conditions. Fully 63 per cent, of the cases are rachitic 
i Pischl). The percentage of rachitis must, of course, vary in differ- 
ent countries, but the case- coming under my notice have been chiefly 
of that character. The condition i> not, as is frequently supposed, a 
rare one. I have regularly seen a number of these cases yearly. 
Many cases of tetany are not recognized as such by the physician. 
< 'old, entozoa, infection- of the gut, chronic intestinal disturbances 
of all kinds, rachitis, an enlarged thymus (Escherich), have all in 
turn been regarded as etiological factors. On the other hand, the 
general trend of opinion i- to attribute the affection to a toxaemia 
probably originating in the gut and expending itself on the peripheral 
motor nerves. Fully 7:5 per cent, of Fisehl's cases had shown in- 
testinal disturbance-. The fact that the condition occurs in early 
infancy and in some respects resembles ;i normal state, to he de- 
scribed later, will account for it- being frequently overlooked by the 
physician. 

Morbid Anatomy. — No definite account of the changes in the 



480 DISEASES OF THE NERVOUS SYSTEM. 

nervous system or elsewhere has as yet been given. Langhans has 
described a peri-arteritis and phlebitis in the white commissure and 
cervical portion of the cord. Gowers, without any positive data, 
assumes that there are some changes in the motor cells of the cord 
which cause the increased irritability of the peripheral motor nerves. 
Fischl in a recent article has published the post-mortem changes 
in his fatal cases. He makes, however, no comment on them. He 
found hydrocephalus interna and externa, oedema of the brain and 
meninges, tuberculosis of the brain, hemorrhagic infiltration of the 
cerebellum and meninges, chronic intestinal catarrh, and broncho- 
pneumonia. The affection occurs under the most diverse conditions. 

The symptoms consist of muscular contractures and phenomena 
connected with the peripheral motor nerves, which are known as 
Trousseau's phenomenon, Chvostek's facial symptom, and Erb's signs 
of increased electrical excitability of nerve and muscle. 

Muscular Contractures. — These come on without any premonitory 
symptoms. The infant or child may have been in good health, or 
may have been suffering from intestinal disturbance. There are 
two distinct forms of contracture in infants, in one of which the 
hands and arms take the position assumed in driving horses (Plate 
XX.). The arms are pressed against the thorax, the forearms flexed 
on the arms, and the fingers tightly flexed over the thumb into the 
palm of the hands. The hand itself is strongly flexed on the fore- 
arm. The lower extremities may be adducted toward the median line, 
the thighs flexed on the abdomen, and the legs on the thighs. The 
feet are as a rule extended in the equinus position and the toes over- 
flexed on the plantar aspect of the foot, the whole foot being slightly 
curved inward. After the contractures have lasted some time, there 
is oedema of the tissues over the dorsum of the foot. In the 
second set of cases the fingers are overextended, as shown in Fig. 
137. The arms and lower extremities also take the position 
of flexion. These contractures are painful ; the patient cries as if 
in great pain when an attempt is made to straighten the fingers or 
extremities. There may be a temperature of two or three degrees. 
The contractures may diminish, and there may be an interval in 
which the only symptoms are such as may be attributed to the 
increased mechanical and electrical irritability of the peripheral 
nerves. There may also be eclampsia. The eclamptic attacks are 
very dangerous. I have lost 2 cases in such seizures. Other musclesy 
such as the abdominal or thoracic, may be the seat of contracture. 
In the latter case there may be cyanosis. 

I have seen cases in which all the muscles of the body were 
involved very much as in tetanic conditions. In one case there were 
stiffness of the muscles of the neck and loss of consciousness. 
Trismus is rare, and certainly does not occur at the outset, as in 
tetanus. The muscles of the face may be subject to contracture. 



PLATE XX. 




Tetany. Infant nine months of age. Shows the driving 
position of the fingers, hands and arms, overextension of 
the feet and flexion of the toes. 



TETANY, 



481 



The brow is wrinkled, and the thee has an anxious expression. If 
the muscles over the zygoma are tapped, there is an instantaneous 
contracture or spasm of the orbicularis palpebrarum. In some cases, 
if the muscles of the face or the forehead are tapped, there is an 
instantaneous contracture of the muscles of the face, and some- 
times of other muscles of the body. This is called the facial 
phenomenon of Ghvostek. If the nerves and arteries at the bend 
of the elbow are compressed, the characteristic tetany position is 

Fig. 137. 




Tetany. Extension of the finder*, flexion <>f the arms, flexion of the toes. Child, eighteen 

months of age. 



produced in the muscles of the hand and fingers. This phenomenon 
was first noticed by Trousseau, and bear- his name. Erb established 
the fact that there is increased irritability of nerve and muscle to 
the faradie and galvanic current. If the muscles or nerves elsewhere 
in the body are tapped, or if pressure ifl brought to bear at the point 
<»f exit of the nerve-trunks, there is an excessive irritability to this 
mechanical stimulus. The knee reflex i< increased. 



31 



482 DISEASES OF THE NERVOUS SYSTEM. 

Duration. — The disease may last a few hours, days, or weeks. 
In many cases the contractures disappear for a time, leaving the 
patient perfectly free from symptoms. They may return in all their 
original severity. The attacks leave the peripheral nerves in a con- 
dition of increased excitability. In such cases both the Chvostek 
and Trousseau phenomena may be present. 

The diagnosis of fully developed tetany is based on the presence 
of muscular contractures, of increased mechanical irritability of the 
peripheral nerves (as evinced in Chvostek' s symptom), and the pres- 
ence of Trousseau's phenomenon. There are cases of tetany in which 
the facial symptoms are lacking. On the other hand, I have, in 
cases in which there was laryngospasm without contractures, obtained 
both the facial and Trousseau phenomena. 

The Relationship of Laryngospasm to Tetany. — Escherich, his 
pupil Loos, and also Ganghofner, have recently called attention to 
the fact that laryngospasm is present in a certain number of cases 
of tetany. They also found that cases of laryngospasm which did 
not present contractures, did show the facial phenomenon of Chvostek 
and the Trousseau symptom. They concluded that laryngospasm 
was a manifestation of tetany, whether the muscle contractures were 
present in the extremities or not. Their observations have been 
amply confirmed, but not all observers are as yet willing to accept 
laryngospasm without contractures of the muscles of the extremities, 
as true tetany. The views of Kassowitz and Hochsinger are at 
variance with those of Escherich. They consider rachitis the funda- 
mental cause of laryngospasm, if not of tetany. 

The term latent tetany has been applied to those cases which show 
no muscular contractures or laryngospasm, but in which the facial 
Trousseau or Erb phenomenon may be elicited. 

Prognosis and Mortality. — The prognosis in the sporadic cases 
is very good. Parents should be cautioned in regard to the excita- 
bility of the patient and the possibility of eclampsia, with its fatal 
consequences. I have lost 2 cases in convulsions. The persistent 
cases may be complicated with other affections, such as tuberculous 
meningitis. If such is the case, the outcome is, as in the primary 
disease, fatal. Epidemics in hospitals for children present unfavor- 
able features; Escherich lost 37 per cent, of his cases. 

Treatment. — The bowels should first be evacuated. Calomel is 
given in grain \ (0.03) doses two or three times daily. If there is 
any disturbance of the gut, the patient is given a high enema once a 
day. Milk is suspended until the movements take on a more favor- 
able appearance. The infant is kept under the influence of the 
mixed bromides of potassium, sodium, and ammonia. If there is 
eclampsia or increased irritability, a warm bath is given at least once 
a day. The patient is kept quiet and not disturbed much, No 
attempt to straighten the limbs should be made, since it causes pain. 



CONGENITAL STRIDOR OF INFANTS. 483 

CATALEPSY. 

Epstein has recently described a condition in children closely 
resembling a similar affection in the adult. He has described it as 
catalepsy occurring in infants poorly nourished and rachitic. The 
ages of bis eases ranged from eighteen months to three and one- 
half years. Epstein believes there is a disturbance of the psy- 
chomotor functions. The phenomenon was observed by him chiefly 
in the lower extremities. Either extremity on being lifted into the 
air would stay there for a length of time in any position of flexion 
or extension in which it was placed. This phenomenon was not pres- 
ent during sleep, nor was it accompanied by any muscular rigidity 
or increase of mechanical or electrical irritability of the peripheral 
nerves. I have met a marked case of catalepsy following an attack 
of typhoid fever in a boy of four years. The hands, arms, and lower 
extremities would remain for long periods of time in the position in 
which they were placed. The boy would sit for long periods staring 
ahead, without winking the eyes. 

MYOTONIA. 

Myotonia physiologica neonatorum is a term applied by Hoch- 
Binger to the normal tendency of the newly born infant to flex the 
finger-, arm-, and lower extremities. There is a slight rigidity 
which i< a hypertonicity of the muscle, and which lasts until the 
third month. The position closely resembles that of the extremities 
of the foetus in utero. The myotonia is exaggerated if the infant 
becomes ill with any intercurrent affection, such as syphilis. The 
condition cannot be mistaken for tetany if the differences between 
the normal and the abnormal states of the peripheral nerves are 
borne in mind. 

CONGENITAL STRIDOR OF INFANTS. 

(Thomson. | 

This rare condition has for a long time been classified by writers 
as a mild form of laryngismus stridulus. I have seen one case in 
which there was also laryngismus. The affection is a distinct one, 
i- generally congenital, and appears soon after birth. Some years 
ago, I presented a case of the kind before the Pediatric Section of 
the Academy of Medicine of New York. Since then 1 have seen a 
number of cases, and have records of four which 1 studied. Thom- 
bod has fully described and studied the affection. The infant is 
usually in other respects normal, but I have seen the condition in 
infants with siL r n- of rachitis. The aires of the patients varied from 
nine weeks to twelve months. In one case there was a history of 



484 DISEASES OF THE NERVOUS SYSTEM. 

attacks of laryngismus stridulus, occurring shortly after birth. In 
most of the cases, the symptoms were noticed soon after birth. The 
respiration is more or less noisy, being sometimes scarcely audible and 
at other times so loud as to be heard at some distance. Inspiration 
is accompanied by a peculiar croaking, grunting noise. As a rule, 
expiration is noiseless, but it may be accompanied by a grunting 
sound, there being short intervals in which no sound is heard. The 
infants are not at all disturbed by the condition. They sit and play, 
emitting this peculiar croak while breathing. In mild cases, nothing 
is seen in the thorax. I have, however, seen the drawing inward 
of the suprasternal region which Thomson describes. In one case 
the noise was louder at night. If the stethoscope is held over the 
situation of the vocal cords, it will be ascertained that the sound is 
produced in the larynx and not in the pharynx. 

The causation is obscure, but the theory advanced by Thomson 
is probably correct. He surmises that there is an ill-coordinated 
spasmodic action of the muscles of respiration, choreiform in char- 
acter and similar to that present in stammering. Others have at- 
tributed this condition to the presence of an enlarged thymus 
(Yariot). Toward the second year of life, the condition gradually 
disappears spontaneously. 

LARYNGISMUS STRIDULUS. 

(Spasm of the Glottis.) 

Laryngismus stridulus is a spasmodic functional nervous disorder 
of the glottis, also involving the muscles of inspiration and expira- 
tion. 

Occurrence. — The affection is more frequent in boys than in 
girls. It is most common in the first year of life. The majority 
of the cases occur before the end of the second year. Kassowitz 
found 348 of 370 cases to occur before that time. It may occur in 
the newly born infant (Henoch, Kassowitz). Most of the infants and 
children affected by this disorder are subjects of rachitis and also 
show signs of craniotabes. Henoch estimates the frequency of rachitis 
at 75 per cent. Only one of the cases of Kassowitz did not show its 
signs. All but 48 showed craniotabes. On the other hand, Boral 
shows that 4 per cent, of all children with rachitis have laryngismus 
stridulus. 

The etiology of this affection is obscure. Although rachitis is 
so frequent an accompaniment of the disorder, it may not yet be 
assumed that it is the exciting cause. Craniotabes, which is a part 
of the symptom-complex, has been regarded as the cause (Elsasser). 

Escherich, Loos, Gee, and Ganghofner have placed laryngismus 
stridulus in the same category as tetany, and trace it to the same 
exciting cause. Reflex irritation from the stomach acting through 



LARYNGISMUS STRIDULUS. 485 

the vagus, is the theory of Baginsky. In many cases which have 
terminated fatally an enlarged thymus has been found. On the 
other hand, there have been post mortems which showed a rather 
small thymus and slightly enlarged hroncial nodes (Baginsky). 

Morbid Anatomy. — No definite study has been made of the 
changes found in the fatal cases. Most cases show oedema of the 
brain and some fluid in the ventricles, rachitis slight or pronounced, 
the thymus small or enlarged, and the lymph-nodes slightly enlarged. 
The cases with enlarged thymus thus far published have not been con- 
vincing. Children with enlarged thymus die of other disorders, and 
without having had during life any symptoms of spasm of the glottis. 

Symptomatology. — The spasm or paroxysm comes on suddenly. 
Without the least warning, the child throws the head back and 
stops breathing ; the face becomes livid, the arms are flexed and the 
hands clenched. No respiratory movement takes place for a few 
seconds. There is then a long-drawn whistling or crowing inspira- 
tory sound. This is the classical form of spasm of the larynx. 
The paroxysm may begin with a piping, inspiratory sound. Apnoea 
lasting for a varying length of time succeeds, and is followed by a 
loud or silent expiration. Apnoea may appear first, and be followed 
by several noisy explosive expiratory movements, which may be 
succeeded by several noisy crowing inspiratory sounds. The pic- 
ture is usually that of spasm of the glottis as first described, in 
which the breathing -tops entirely. The attack may come on 
during absolute quiet or during sleep, the onset of the attack causing 
the child to wake. The paroxysms may be brought on by excite- 
ment, a draught of air, or by pressure on the larynx. They are 
of all degrees of severity. Some infants show a form which is 
very disquieting. In a fit of crying the child takes a number 
of noisy inspirations and expirations, and then stops breathing, 
becomes cyanosed, clenches the hands, and threatens to pass into an 
eclamptic paroxysm (expiratory apnoea), when suddenly a deep 
inspiration occurs and the danger is passed. Some cases of the 
classical form have eclamptic seizures. There may be convulsions, 
especially in the form described as expiratory apnoea. In all of 
these cases there i- the ever-present danger that the glottis and the 
muscles of respiration will fail t<> relax, thus causing death with con- 
vulsions. The number of attack- of spasm of the glottis may reach 
twenty or thirty a day, or they may be very infrequent, occurring 
<»nly once every few day-, week-, or months. In all the forms, 
including the classical <>ne just detailed, the spasm involves not 
only the glottis, but also the diaphragm and other muscles of respi- 
ration. The infants may show no symptoms after the paroxysms. 
On the other hand, some infant- seem to be overcome and pass into a 
stupid state la-tim: for fully ten minute- (Henoch). It is difficult to 
estimate the degree of consciousness during an attack, but even in 



486 DISEASES OF THE NERVOUS SYSTEM. 

the mildest forms there may be a momentary loss of consciousness 
(Henoch). Most cases show the facial and Trousseau symptoms of 
tetany and increased irritability of the peripheral nerves. 

The prognosis of spasm of the glottis is good. The danger lies 
in the eclampsia, during which death may supervene. 

The diagnosis is not difficult. There are all degrees of severity 
of the spasm, ranging from partial to complete closure of the glottis. 
In the latter form a rachitic infant in a paroxysm of crying is fre- 
quently heard to give several inspiratory crowing sounds without hav- 
ing any further symptoms. There is a species of inco-ordination. 
These cases may at intervals develop typical paroxysms. The par- 
ents should be warned of this possibility. The forms of spasm of 
the glottis which have just been described should not be confused 
with spasm or difficult breathing due to pressure of a retropharyn- 
geal abscess or suppurating gland upon the larynx. 

Complications. — Pertussis may complicate a case of spasm of 
the glottis. Cases thus complicated give a grave prognosis (Henoch). 
Tetany has been elsewhere mentioned as an accompanying condition. 

Treatment. — During the Attack. — The infant is carried to an 
open window. A draught of air is allowed to blow in its face or a 
few drops of water are thrown in the face. This is done to excite 
a reflex relaxation of the glottis. The head should be held low, as 
in ordinary eclampsia. If relaxation of the glottis does not occur 
and convulsions set in, a few drops of chloroform may cause the 
muscles of respiration and those of the glottis to relax. Intubation 
and tracheotomy have been performed at this crisis, when the breath- 
ing threatened to cease permanently. If, however, as sometimes 
happens, the muscles of respiration are also involved, the paroxysm 
will occur with the tracheotomy tube in the trachea. Stork has 
published a case in which the insertion of a tracheotomy tube had 
not the least influence on the paroxysms. This is a very important 
observation, and raises the question of the propriety of intubating 
or performing tracheotomy. On the other hand, cases have been 
intubated and resuscitated with artificial respiration (Pott). In the 
intervals, the treatment should be chiefly directed toward the rachitis. 
The feeding should be carefully attended to ; the infants should, if 
possible, be breast-fed. They should be shielded from the least 
excitement. Bathing in cold water has not in my experience been 
productive of good results. 



EPILEPSY. 

Epilepsy is not a disease peculiar to infancy and childhood. It 
is discussed here simply to emphasize the peculiarities of the affec- 
tion as seen in children. It is a true disease of the nervous system, 



EPILEPSY. 487 



and has nothing in common with and no demonstrable relationship 
to infantile convulsions. Fifteen per cent, of the cases of epilepsy 
occur before the fifth year of life. Henoch has seen a case in an 
infant one year of age who bad convulsions beginning with a cry 
and during which the infant bit the tongue. He describes another 
case in a child three years of age, in which the attack began with 
vertigo. In another case, in a child three years of age, the patient 
fixed a point and ran blindly toward it. The latter appears to have 
been a case of tk procursive epilepsy." 

Etiology. — According to Growers, in two-thirds of the cases of 
epilepsy in children the parents are neurotic and hysterical. Chorea 
in the mother will often manifest itself in epilepsy in the child. 
Infantile palsy or traumatism is more frequently than heredity the 
cause of epilepsy. Epilepsy following slight palsy is likely to be 
mistaken for hereditary epilepsy. 

Symptoms. — In children, as in the adult, there are no symptoms 
in the intervals between the attacks. Only such results of attacks 
as a bitten tongue or local traumatism are seen. There are, as in the 
adult, two distinct forms of epilepsy — grand and petit mal — between 
which there may be all variations participating in the peculiarities 
of both forms. In grand mal there is the aura, sensory or psychic ; 
it is present in a large percentage of the cases in children. 

Baginsky calls attention to a case in which epigastric pain was 
the aura preceding the attack. The other forms of aura are numb- 
ness and tingling of the extremities, general restlessness and irri- 
tability and auditory phenomena in which a peculiar cry of an animal 
is perceived. There may be a hissing sound. An aura referred to 
the sense of taste is very rare, and most neurologists do not make 
note of having found it in any case. In children the perception 
of peculiar odors just prior to the attack occurs as a form of aura. 

After the aura, the attack begins with a cry followed by sudden 
1— of consciousness and tonic or clonic spasm of the muscles, which 
maybe unilateral, general, or partial. The pupils dilate ; there is 
Spasm of the respiratory muscles and those of the jaw, as well as 
foaming at the mouth and biting of the tongue. The spasm then 
relaxes, the movements become first clonic and then intermittent, 
there i- involuntary passage of urine and feces, and consciousness 
gradually returns, the patient passing into prolonged stupor and pro- 
found sleep. Some of these symptoms may be absent, but the loss 
of consciousness, dilated pupils, spasm, and the succeeding profound 
sleep are constant. In the majority of cases, the presence of any two 
of these will be sufficient for making a diagnosis. 

Convulsions. — General convulsions indicate hereditary epilepsy. 
Convulsions may at first be partial, but in the majority of cases 
eventually become general. Partial convulsions indicate disease in 
the motor areas. The attack- taking the form of petit mal may 



488 DISEASES OF THE NERVOUS SYSTEM. 

be so slight as to be mistaken for fainting spells. Such attacks 
may occur in young children. One of my cases was in a child five 
years of age. An epileptic spell is momentary ; a fainting spell is 
gradual, there are no vasomotor disturbances, and the pupils do not 
dilate. Henoch and others record cases in which the children 
momentarily stop the occupation in hand, stare into vacancy, and 
then recover themselves without having any recollection of the inter- 
ruption. In other cases there is an irritable attack or mild maniacal 
outbreak. In .some cases the child passes into a state of mental 
confusion in which it performs acts unconsciously. Attacks of 
double consciousness or narcolepsis are rare in children (Sachs). 

Attacks of grand mal are sometimes associated with a rise of 
temperature. A case recently came under my observation in which 
a girl of eight had as many as forty convulsive seizures in twenty- 
four hours. There was a slight rise of temperature which could not 
be traced to any cause other than the convulsions. Thomson and 
Oppenheim have shown that there are a concentric limitation of 
vision and a diminution of general sensibility for some time after the 
epileptic attacks. 

Diagnosis. — Epilepsy must be differentiated from syncope, 
hysteria, post-hemiplegic convulsions, and tumor of the cerebrum. 
The peculiarities of an attack of syncope and hysteria have been 
dilated upon. The post-hemiplegic convulsions will, in the intervals, 
reveal the paralyses and contractures with increase of deep reflexes. 
Attacks of convulsions caused by tumor are confined to groups of 
muscles if the tumor is in the motor area, and are combined with 
optic neuritis if the chiasm is directly or indirectly the seat of pressure. 

With tumor, there are in the intervals peculiarities of the gait 
which aid in diagnosis. 

The treatment of epilepsy is essentially the same in children as 
in the adult subject. 

PAVOR NOCTURNUS. 

(Night-terrors.) 

There are two forms of this affection — the primary or idiopathic 
and the symptomatic form. In both, the children retire to sleep 
and after an hour or two suddenly awaken from deep slum- 
ber with a shriek or cry. They are pale, greatly terrified, and 
grasp at the empty air. In incoherent, broken phrases they try 
to collect their thoughts. Some children see terrifying visions and 
either cling to the bystander for protection or try to get out of 
bed to escape an imaginary danger. After being quieted the 
children fall asleep, and when questioned the next morning have 
no distinct recollection of what has occurred. These attacks may 



CHOREA. 489 

occur every night for days, weeks, or months. They rarely occur 
twice in the course of the same night. 

The idiopathic form of this affection may occur in children 
who are naturally of a nervous temperament without any apparent 
exciting cause. I have seen it in children who were distinctly the 
opposite of nervous, and who were well nourished and good natured. 
The night-terrors may follow epilepsy or they may be so severe as 
to he the exciting element in precipitating an attack of chorea. 
Children sometimes have real hallucinations, which may be present 
even during the (lay (Henoch). It may, however, be said that 
hallucinations during the day are really not included in the idio- 
pathic form. This affection occurs chiefly up to the time of 
second dentition. Forms of terror in older children are hysterical. 
Adenoids are supposed to be an etiological factor, but this is doubtful. 
It is only in the symptomatic form that children, after having com- 
mitted some error in diet, awake with the symptoms above described. 

The prognosis is good. The affection never precedes insanity. 
It subsides under treatment or disappears spontaneously. 

Treatment. — In the symptomatic form, the meals should be so 
arranged that the lightest repast is that taken in the evening. In 
the idiopathic form, bromide of potassium is most useful. It is 
administered in one dose, an hour before retiring. The children 
should not be too active mentally during the daytime. Visitors 
should be restricted to certain hours. Play and sport in the open 
air are indicated. The school tasks of older children should be 
completed in the afternoon. 

CHOREA. 

(St. Vitud Dance; Sydenham' 's Chorea.) 

Chorea is a nervous disease characterized by irregular involuntary 
movements or twitchings of some or all of the muscles of the body. 
It is accompanied by muscular weakness and mental disturbances. 
In some cases there is endocarditis. 

Classification. — Chorea minor is an acute disease described by 
Sydenham. Chorea major is a hysterical disorder; under this head- 
ing are included the chorea elect pica, and the dancing mania with 
rhythmical motion-, of the Middle Ages. 

Chorea insaniena Is the fatal form of acute chorea minor. 

Laryngeal chorea is n hysterical affection (Growers). 

Choreiform affections or pseudochoreas comprise the cases of tie 
convulsif of French writers and other forms of habit-spasm, local 
or general. 

In addition there are forms of chorea which are symptomatic 
or secondary to infantile palsies. Huntington's chorea is a chronic 
progressive affection of a hereditary nature. 



490 DISEASES OF THE NEEVOUS SYSTEM. 

All these forms of chorea except chorea minor and insaniens 
should be excluded from the category of Sydenham's chorea. 

The epidemics of so-called chorea, occurring in schools, are prob- 
bly hysterical disorders which are the result of imitation and not 
true Sydenham's chorea. 

Frequency and Etiology. — Chorea is more common among 
female than male children. Of 554 cases collected by Osier, 
70 per cent, were of the female sex. It rarely occurs before the 
fourth year. Starr's statistics of 1400 cases show 8 at the third 
year. Cases are recorded as occurring in newly born infants, but 
are not accepted by all authors as authentic. The disease is most 
common from the fifth to the fifteenth year. Fifty per cent, of 
Starr's 1400 cases occurred before the tenth year, and 75 per cent, 
from the fifth to the fifteenth year. Of 83 cases of chorea occur- 
ring in my ambulatory and hospital service, 23 were of the male 
and 60 of the female sex. Ten children were under the age of five 
years, and 67 cases occurred from the fifth to the tenth year. Thus, 
the greatest frequency is at the latter period. Only one case occurred 
in a very young child (two and one-half years). The disease is 
found in children in all walks of life. Children of a nervous, 
ambitious temperament with a hereditary neurotic history are more 
prone to contract this disorder than those of a more equable dispo- 
sition. It is therefore more common in towns and large cities 
than in country districts. In some cases there is a history of 
fright or traumatism, either immediately preceding an attack or 
coincident with its onset. It is as yet impossible to say, how- 
ever, whether there is any relation between chorea and these occur- 
rences. They may have some influence in developing latent tenden- 
cies to the disease. An attack will often be initiated by a scolding 
or chastisement on the part of parents. The spring months show the 
greatest number of cases, the least number occurring in the late 
autumn. There also appears to be a correspondence in the preva- 
lence of cases of chorea and rheumatism at certain periods of the 
year (Osier, Lewis). The relation of a condition of lymphatism 
(adenoids or nasal catarrh (Jacobi) ) to true Sydenham's chorea is 
not generally accepted. Errors of refraction in the eyes also seem 
to be a predisposing cause of the outbreak of choreic attacks, 
(de Schweinitz). These can scarcely be regarded as a direct cause 
of Sydenham's chorea, but acute articular rheumatism may be so 
considered. Rheumatism seems to run in families in which the 
children have chorea. Osier finds that 15 per cent, of his cases 
are of such families. Of the subjects of chorea, fully 21 per cent, 
show a history of rheumatism (Osier). These figures corre- 
spond more or less to the statistics of Townsend, 21 per cent.; 
Starr, 21 per cent, in 1400 cases; and my own cases, 18 per cent. 
Crandall gives the highest frequency of rheumatism in cases of 



CHOREA. 491 

chorea (54 per cent.). In the majority of cases the rheumatism pre- 
cedes the chorea (Sec). I have seen one case of chorea preceding an 
attack of rheumatism in a child four years old. I believe that, with 
cases of rheumatism of the acute articular type, there should also be 
included those of articular pains without swelling of the joint. The 
forms of rheumatism with chorea giving the so-called subcutaneous 
fibrous rheumatic nodules are rare in this country (Osier). 

Chorea may complicate any acute infectious disease, such as 
scarlet fever, whooping-cough, measles, diphtheria, typhoid fever, 
and forms of sepsis. There are, however, no definite data of the 
exact relation, if there be such, between chorea and the infectious 
diseases. The theory that an attack of any of these diseases will 
cut short an attack of chorea is not borne out by clinical experience 
(Henoch). 

Morbid Anatomy. — The pathology of chorea is still incomplete 
and can therefore be merely indicated. Hyperemia of the brain 
and cord were found by Pye-Smith and Ogle. Anaemia and prolifer- 
ation of connective tissue were recorded by Steiner. In the cases of 
Meynert there was hyaline degeneration of the nerve cells of the 
central ganglia. Flechsig mentions hyaline degeneration of the 
lenticular nucleus. Dana studied some cases in which he found 
hypenemia of the brain, and degenerative changes in the walls of 
the bloodvessels of the white substance, with perivascular exudation 
and accumulation of leucocytes. Jackson has advocated the embolic 
theory (endocardial). At present there is a great preponderance of 
evidence in favor of the infectious theory. Berkeley found staphylo- 
cocci in the blood in a fatal case of chorea. In another case, 
Xaunyn found cladothrix in the meninges and endocardial vegeta- 
tions. It is certain that just as rheumatism and endocarditis are 
infection- diseases, 80 chorea in many cases can only be understood 
on that theory. (V-ari— Demel has experimentally shown that the 
centra] nervous system i- peculiarly susceptible to certain pathogenic 
micro-organisms and their toxins. The staphylococcus and its 
toxin- when injected experimentally under the dura mater cause the 
formation of small foci of inflammation, and symptoms very similar 
to those of chorea. 

Symptoms. — Children will at the outset of this disorder exhibit 
mild symptom- of nervous irritability, will be cross, have outbreaks 
of peevishness and temper, will drop things, and be generally 
careless in their habits. There i- sometimes a history of night- 
terrors or morose crying spells. There is likely to be loss of appe- 
tite ; headache is not uncommon, and there may be pains in the 
limbs or joint- and general restlessness. The disease may begin in 
a certain set of' muscles, or in the muscles of one-half the body and 
thence spread to the whole trunk. Of 301 cases of the statistics of 
Sachs, there was hemichorea or involvement of one set of muscle- in 



492 DISEASES OF THE NERVOUS SYSTEM. 

67. Of Starr's 1400 cases, 951 were general and 449 unilateral, the 
right side being affected more frequently than the left. When fully 
developed, the picture presented by these patients is so characteristic 
as to be easily recognized. On the other hand, the popular notion, 
so prevalent even among physicians, that every twitching is choreic, 
has led to grave errors. The following are the main symptoms : 

Motor. — The twitchings usually begin in the right hand, only 
rarely in the legs. After a time there are incessant, irregular, awk- 
ward twitchings of all the muscles of the body, which are intensified 
by volition. If the child is directed to stand still, with the feet 
together and the arms and hands held out at right angles to the 
body, the motions are intensified. If it is told to close the eyes, 
there is a distinct swaying of the body. The movements are not 
only irregular, but awkward. The patients trip in walking, upset 
their food and drink, and cannot button their clothing with ease. 
As a rule, the muscular twitching ceases in sleep, but it may per- 
sist. The muscular power is weakened, although distinct paralysis 
does not occur. The muscle is more paretic than paralytic. Some 
children let the arm hang at the side. There is wrist-drop when 
the children are asked to hold out the arms. The tongue is affected 
in all cases. Sachs places much diagnostic value on the choreic 
movements of that organ. When children are asked to show the 
tongue, they will protrude the organ with a jerk, then withdraw 
it and twist it here and there in the cavity of the mouth. When the 
tongue is held out quietly, fibrillary twitchings in the organ may be 
detected. Electrical reaction or irritability of the muscles in chorea 
can be tested only when the disease is unilateral. In some cases there 
is no change. In others, according to Gowers, there is a distinct 
increase in the galvanic and faradic irritability of nerve and muscle. 
The muscles of the hands, face, and extremities are all involved in 
the twitchings of the voluntary muscles. The involuntary muscles, 
such as the cardiac muscle, are not affected. Their involvement 
has long been a matter of discussion. 

Disturbances of sensation are not common. Children have the 
arthritic pains. Numbness, tingling, pricking, and anaesthesia of 
the pharynx are recorded. Attacks of multiple neuritis and epileptic 
seizures should be regarded as complications. The reflexes are not 
markedly affected. They may in rare cases be slightly diminished 
or increased (Henoch). Any marked change in the reflexes may 
be traced to changes of an organic nature, in the cord. The occur- 
rence of headaches or eye-strain as concomitant conditions has been 
referred to. 

Urine. — The urine may contain albumin. Cases with nephritis 
as a complication have been reported (Thomas). 

The speech is affected in 25 per cent, of the cases. The patients 
hesitate and mumble their words or there is difficulty of phonation 



CHOREA. 



493 



due to incoordinate action of the larynx. Laryngeal chorea, in 
which there is a distinct sound resembling a bark, is seen in rare 
eases. It is classified by Grower as a hysterical disorder, truly 
choreic. I have never met a case of the kind in a child. Deglu- 
tition may be affected because of the muscular inco-ordination. 

The cardiac symptoms are the most important clinical feature 
of chorea. There is very little doubt, that in a fixed proportion of 
cases, rheumatism plays an important role and that the rheumatic 
poison, whatever it may be, expends its force upon the endocar- 
dium and pericardium. In 20 per cent, of the cases of Osier and 
in 12 }>er cent, of Starr's material, organic lesions of the heart 
were found. 

The frequency of cardiac disease in chorea varies as given in 
hospital and ambulatory statistics. The severer cases come to the 
hospitals. The majority of the ambulatory cases are mild. Thus 
39 per cent, of my hospital cases showed a cardiac lesion (endocar- 
ditis), while only 13 per cent, of the ambulatory cases were similarly 
affected. There would thus be an average of 26 per cent, of both 
hospital and ambulatory cases. The lesions in simple chorea 
referable to the endocardium usually affect the mitral valve. Of 
17 valvular lesions, 14 occurred at the mitral valve (systolic). 
The aortic valve was affected in 3 cases (Fig. 138). Pericarditis 

Pig. 138. 



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chorea. Recurrent attack of moderate severity. Systolic murmur over the aortic area. 
Fourteen days of the temperature is shown here. Child, twelve years of age. 



occurred in one of my cases. In the majority of cases in which 
there was endocarditis either the patient or the parents gave a rheu- 
matic histo/y. On the other hand, not all murmurs of the heart 
are organic. In 9 per cent, of Starr's 1400 eases, there were func- 
tional murmurs heard at the base and over the pulmonic area, 
early or late in the disease. A gentle blowing at the apex which 
is heard to the left of the sternum and is not conducted into the 
axilla or arteries is heard late in the affection, and is undoubtedly 
haBmic or myocarditic (Osier). I have heard these murmurs in 
many cases and have come to the same conclusion. Murmurs 
may also arise at the tricuspid orifice. The organic murmurs are, 



494 



DISEASES OF THE NERVOUS SYSTEM. 



as stated above, produced at the mitral orifice in the greatest 
number of cases. They may arise in the course of the disease or 
may appear during a relapse. Such cases will show a temperature 
(Fig. 139). The temperature may after a time become normal, and, 
in a week or more, while the chorea is still in progress there may 
be a rise lasting for a day or more, after which it may then again 
subside to the normal. The temperature may be but a fraction of a 
degree above the normal, and the diurnal course may be distorted 
or subnormal (Jurgensen). There is thus clinically a true endo- 
carditis. This form of endocarditis may pave the way for future 
chronic valvular disease. Under the heading of Chorea Insaniens, I 
have noted two fatal cases of this form of heart disease. Chorea 
of the heart muscle is not clinically recognized. Pericarditis with 
endocarditis may occur in cases of recurrent chorea. I have seen 
two such cases. Functional disturbances such as palpitation and 
arhythmia also occur. 

Fig. 139. 



12 3 6 9 12 3 (i 9 12 3 



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ii 



Chorea. Endocarditis. Previous attack six months prior to the present illness, which 
was of five weeks' duration before the above observation. Pains in the joints, especially the 
knee. This curve shows two weeks of the endocarditis. Recovery. Female child, five 
years of age. 

Temperature. — There are some forms of chorea minor without any 
signs of endocarditis, which run a course with a slight temperature, 
the cause of which is undetermined. Some authors think that there 
may be a latent endocarditis in these forms of chorea (Henoch). If 
endocarditis is present, there may be a temperature only slightly 
above normal. In most cases of chorea, there is no temperature 
(Fig. 140). Fatal cases of chorea, with few exceptions, show signs 
of endocarditis. Osier has made a study of 80 such cases, and 
found only 5 which post mortem did not show changes in the 
valves. 

The mental symptoms are in some cases marked. The patients 
show apathy and depression. The children often, while they are 
under treatment, have spells of mental depression and fits of crying. 
It is only in the cases of insaniens, that delirium occurs. In severe 
cases, there is a period of more or less mental depression, extend- 
ing far into convalescence. 

The diagnosis of chorea minor is not difficult in the majority of 
cases. The picture is a very characteristic one. There are slight 



CHOREA. 



495 



twitching*, which so closely resemble habit movements that it is 
often not easy to come to a conclusion in regard to them. Sachs 
thinks that the twitchings of the tongue are a means of distinguish- 
ing the mild eases of chorea from cases of habit movements. If the 
patient is told to show the tongue, the tremors and twitchings of that 
organ and the facial grimaces at once become marked. The move- 
ments of the muscles are more rhythmic in hysteria than in chorea. 
True Sydenham's chorea should be distinguished from the chorea 
and athetoid movements seen in eases of infantile palsy. The his- 
tory of the cases, the paralysis, the condition of the reflexes and 
the contractures will be of assistance in making a diagnosis. True 
Sydenham's chorea should also be differentiated from cases of tic 
eonvulsif and habit movements. A diagnosis of chorea, made in a 
ease which has lasted for a year or more, is open to doubt. 



Fig. 140. 





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Chorea, without endocarditis, two months in duration. 

child, nine years of age. 



No rheumatic history. Female 



The duration of chorea is variable. It may last from three to 
ten week-, and may recur. The recurrent attacks are not neces- 
sarily any more severe than previous attacks. Fully one-third of the 
cases in some statistics show two or more attacks. Of Starr's 1400 
cases, 365, or 2<> per cent., had relapses. One case had nine attacks. 
Starr think- relapses less frequent in private practice than in hos- 
pitals. 

The prognosis of chorea minor is very good. Recovery is the 
rule, but in exceptional cases it may be delayed for fully three 
months. 

The treatment of chorea consists at first in giving the patient 
perfect rest and quiet surroundings. Children are put to bed and 
kept free from excitement. I do not think it necessary to isolate 
them, and it is not wise to do BO, since they may. under such treat- 
ment, become melancholic. An ordinary amount of quiet, BUcb 
as is prescribed in cardiac cases, is all that is usually necessary. 
The patient may be allowed to look at picture-bonks, but not to 
study or to read. A simple, easily assimilable diet is indicated, milk 



496 DISEASES OF THE NERVOUS SYSTEM. 

and eggs being the chief articles. A warm bath is given daily and 
the spine sponged with cool water, as some authors recommend. I 
have not found this necessary in all cases, and would advise it to be 
omitted if the children strongly object to it. Massage is of great 
value with anaemic children in whom the circulation is below the 
average and who have no cardiac disease and no temperature. 

Drugs. — Fowler's solution is used almost as a routine remedy in 
these cases. In my experience its curative effects are doubtful. I 
therefore prefer to give it in small tonic doses, rather than risk 
the ill effects of large dosage. There are cases in which any attempt 
to administer it causes vomiting, and which therefore do m uch better 
without it. In any case it should be well diluted. In this way 
larger doses can be given for a greater length of time than would 
otherwise be possible. 

Cases which show recent or old endocarditis or which have artic- 
ular pains should receive antirheumatic treatment. Alkalies to 
keep the bowels open, alkaline baths, and sodium salicylate are the 
remedies in use in these cases. 

If there is great restlessness, bromides should be resorted to. It 
is a very good plan to combine the bromides of sodium, potassium, 
and ammonium in one mixture. Trional given in grain v (0.3) doses 
several times daily is a very good remedy in this set of cases, espe- 
cially if there is wakefulness at night. 

If on account of the loss of appetite and general mental depres- 
sion it is not possible to give any drugs, the children are simply 
kept quiet and given a nutritious diet. They frequently recover 
without the help of any drugs. In ordinary cases there is no ne- 
cessity of using opiates, such as codeine,. Antipyirin in grain v 
(0.3) doses has been recommended. I have not found it better 
than other remedies. Children who have recovered should be kept 
quiet for fear of a recurrence of symptoms. This is especially 
true of cases in which the heart has been the seat of a recent endo- 
carditis. 

Chorea Insaniens. 

Chorea insaniens is a term applied to the severest form of chorea. 
A large number of these cases run their course with delirium and 
high fever. It occurs especially in female subjects. At the outset, 
there may appear to be nothing more than an ordinarily severe 
chorea, but the patient rapidly becomes worse. Delirium with hallu- 
cinations sets in, finally giving way to incoherency and mania. The 
patients are in incessant motion, and do not sleep at night. The fever 
may mount as high as 107° F. (41.6° C). The cases are in many 
instances fatal. Osier gives a r&sumg of some fatal cases. I have seen 
2 fatal cases of this form. One case occurring during my service 
as interne at Bellevue Hospital was that of a girl of twelve, who 



CHOREA IXSAXIEXS. 



497 



died with symptoms very similar to 
those of acute mania. Another ease, 
seen recently, was a boy of ten years, 
who had for two years previously 
suffered from ordinary chorea. He 
had a mitral regurgitant murmur. 
Two weeks before his death he was 
suffering from a mild recurrence of 
the chorea. While in that state he 
was operated on for adenoids and 
enlarged tonsils. Chloroform was 
administered. Three days after the 
operation the hoy was taken witli a 
chill, the chorea became worse, and 
there was fever. Examination of 
the heart showed endocarditis and 
pericarditis with dilatation of the left 
ventricle. In the second week, the 
boy became delirious, and did not 
sleep at eight. He complained con- 
stantly of pain in the pnecordinm 
and tossed in bed. He died two 
weeks after the onset of the disease. 
There was throughout a high febrile 
movement. A third case was that 
of a boy six years of age, whose 
temperature-curve is herewith ap- 
pended (Fig. 141). This case oc- 
curred in my hospital service. It 
was the boy's third attack of chorea. 
He had chronic cardiac disease. In 
the final attack there was compli- 
cating pericarditis with effusion. The' 
delirium was eon-taut and the choreic 1 
movements incessant. He went into 
a typhoid state, but recovered, his 
mental faculties, however, being 
shattered. During the course of the 
pericarditis there was a polynuclear 
Leucocytosi8, and b~> per cent, haemo- 
globin. 

These cases are t<> be differenti- 
ated from cases of severe simple 
chorea, in which the movement- are 
so incessant that the patients can 
with difficulty be kept in bed. In 

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498 DISEASES OF THE NERVOUS SYSTEM. 

simple chorea there is no delirium and there is a period of quiescence 
at night. 

The treatment of chorea insaniens is symptomatic. The delirium 
and incessant restlessness are controlled with bromide of potassium, 
or sodium combined with chloral hydrate. The use of morphine is 
indicated in cases in which the chloral and bromides are ineffectual. 
Complicating endocarditis and pericarditis are treated as when 
primary. 

FORMS OF TIC. 

(Habit Movements or Spasms.) 

This affection is mentioned in this place to emphasize the im- 
portance of sharply differentiating its forms from true Sydenham's 
chorea. Tic is denned by Gowers as a habitual and conscious 
convulsive movement of one or more of the muscles of the body, 
reproducing some reflex or automatic movement normal to the indi- 
vidual. Osier has classified the forms of tic. There is first the 
ordinary form, in which young people or children develop a spasm 
of a group of muscles, generally of the face. Children do not 
have the form known as idiopathic spasm of adults in which the 
lower extremities are involved. There is contraction of a group 
of facial muscles, such as the orbicularis or the muscles about the 
nose. There are other forms of tic in which mental disturbances 
and explosive utterance of words or .syllables are prominent features. 
If the words are of an obscene character, the condition is called 
coprolalia. In other cases the patients repeat words or sentences 
(echolalia). The so-called laryngeal barks of a hysterical nature 
are, according to most observers, to be classified as forms of tic, and 
not as laryngeal chorea. 

There is a fourth class, which includes those cases in which the 
subject before proceeding to any definite act, such as writing, feels 
impelled to blow on the fingers, pinch the nose, or strike the head or 
thorax. These actions may be regarded as harmless tricks. In 
another form of tic the patients feel impelled to touch objects, such 
as the floor or wall (delire de toucher of French writers). 

RHYTHMIC MOVEMENTS OF THE HEAD ASSOCIATED 
WITH NYSTAGMUS. 

(Head-nodding ; Spasmus Nutans; Gyrospasm.) 
Nystagmus alone is quite frequently observed in infancy and 

childhood. 

Rhythmic movements of the head associated with nystagmus 

constitute an uncommon affection. 

The derangement is functional and occurs in poorly nourished 

and rachitic infants whose nerve resistance is diminished. The 



RHYTHMIC MOVEMENTS OF THE HEAD. 499 

majority of cases give a history of some preceding illness, in the 
course of which the infant has suffered from convulsions. The 

mothers may he of a nervous temperament. The phenomenon which 
at once attracts attention is a rhythmic oscillation of the head in a 
horizontal or vertical direction, or both. On close examination it will 
also be noticed that the eyes have a horizontal, vertical, or oblique form 
of nystagmus, Ebert, (alien, Caille, Gee, Hadden, and Lewi have 
Studied these case-. Lewi reported (> cases from my clinic. The 
_ - of the infants ranged from three to eighteen months. The 
movements were augmented when the infant focussed some at- 
tractive object. The nystagmus, if not marked, may be made 
apparent by holding an object to the right and upward for the infant 
to focus. Lewi as well as Caille* found that the nystagmus ceased 
when the infant was blindfolded. In one case the movements con- 
tinued when the infant was in the recumbent posture. The eye and 
head movements were not synchronous. As a rule the eye move- 
ments were the more rapid. These observers did not agree with 
Hadden in finding that forcible restraint of the head stopped the 
nystagmus. I have been accustomed to see a number of these cases 
yearly. Some of the infants are quite bright and well nourished. 
This statement agrees with that which Thomson recently made. 
Three-fourths of the cases are under the age of twelve months 
(Thomson). 

The etiology of the affection is obscure. It is usually coincident 
with the period of dentition, but may appear as early as the third 
month. Some of the infants live in dark, squalid quarters, and the 
affection ha- been attributed to eye-strain caused by the infant's 
attempts to fix a light as it lies in its crib. This theory would make 
the affection appear similar to that frequently seen in miners (Mag- 
nus). Some of the patients that I have seen lived in well-lighted 
quarter-. 

Rachitis was present in most of my cases. Thomson's experi- 
ence was similar. Henoch gives a physiological explanation of the 
combination of nystagmus with the rotary movements of the head, 
by pointing out that the root nuclei of the nerves of the muscles of 
the neck and throat which rotate the head are adjacent to the ocular 
nuclei, and that any irritation of one set of nuclei may affect the 
other. This explanation has been generally accepted. 

Treatment. — The cases a- a rule recover. They are given out- 
door air, correct food, and a general course of treatment for 
the rachitis. Phosphorus is given as in rachitis. I have also 
prescribed the bromide- of potassium and sodium, grains v (0.35) 
three time- daily, but cannot Bay that they have had curative 
effect-. Tin- cases certainly improved in time. 'flic blindfolding 
suggested by Caille only -top- the rhythmic movements of the 
head temporarily. 



500 DISEASES OF THE NERVOUS SYSTEM. 

HYDROCEPHALUS. 

(Dropsy of the Brain.) 

Hydrocephalus or dropsy of the brain is an abnormal accumula- 
tion of fluid in the subdural space, or in the ventricles of the brain. 
In the former case there is external, in the latter, internal hydroceph- 
alus. Hydrocephalus may be acute or chronic. It may also be 
congenital, secondary, or primary. The last-named form occurs in 
adult subjects (Delafield). 

Acute Hydrocephalus. 

Acute hydrocephalus, internal or external, is a form of serous 
meningeal inflammation which may be primary or secondary. 
Formerly tuberculous meningitis was known as acute hydroceph- 
alus. Forms of acute hydrocephalus, apart from that due to 
tuberculous meningitis, are secondary to acute disease, such as 
typhoid fever, pneumonia, and tumor of the brain, or they follow 
a traumatism or cerebro-spinal meningitis and other forms of 
meningitis of the non-tuberculous variety. 

This form of serous effusion, both when outside and within the 
ventricles, originates in an obstruction of the venous or lymphatic 
circulation. 

The symptoms of the primary form are indefinite. There is 
fever. Headache, rigidity of the neck, nausea, vomiting, stupor, coma, 
and delirium are among the initial symptoms. The pupils are 
sluggish and there may be optic neuritis, convulsions, and paralyses 
of various kinds, including paralysis of the external rectus of 
the eye. The symptoms closely resemble those of meningitis. 
The condition is rare before the end of the first year, and is 
most common between the first and fifth years. 

Course. — In mild forms recovery may take place ; the severer 
forms are fatal. 

Chronic Internal Congenital Hydrocephalus. 

The accumulation of fluid begins in utero. The quantity at birth 
may be small and may afterward increase. It may be large enough 
at birth to obstruct delivery. 

Etiology. — The causes of the condition are unknown. Alcohol- 
ism, syphilis, and tuberculosis of the parents have been regarded as 
predisposing causes, but infants thus affected may be born of per- 
fectly healthy parents. Sometimes several infants with this malady 
are born to one mother. 

Morbid Anatomy. — The quantity of fluid accumulated in the 
ventricles varies. The fluid is perfectly clear and has a specific gravity 



CHROSIC INTERNAL CONGENITAL HYDROCEPHALUS. 501 

of from 1001 to 1009. It contains a trace of albumin and sometimes 
urea, sodium chloride, and cholesterin. The weight may reach twenty- 
seven pounds. The fluid distends the lateral ventricles, the third 
and tilth ventricles, and the fourth to a less degree. The central 
canal of the cord may he dilated (Delafield). The corpus callosum 
is displaced upward. The thickness of the cerebral substance may 
be reduced to a few millimetres. The convolutions may be obliter- 
ated, as may also the basal ganglia. The aqueduct of Sylvius is 
dilated. The white matter of the brain suffers most. The mem- 
brane of that organ may be normal. The ependyma may be thick- 
ened and granular. 

The symptoms are the gradually increasing size of the head 
and the development of idiocy and paralyses as a result of 




Congenital internal hydrocephalus. Infant, nine months of age. 



internal pre— lire on the nervous structures. The cranium en- 
larges so that it becomes disproportionate to the face, which 
remains small. There i- bulging of the occipital and frontal regions. 
The orbital plate- take an oblique direction, causing the eves to 
assume a peculiar -tare ( Pig. 142). The sclera 18 -ecu exposed above 
the cornea. The eye- arc directed downward and are only partially 
c«»v.red by the eyelids. The sutures are forced apart and the fon- 
tanelles are widely open. The anterior fontanelle bulges and pul- 
sates Visibly. The cranial bone- may here and there -how areas of 
thinness resembling those seen in craniotabes. The lambdoid suture 



502 DISEASES OF THE NERVOUS SYSTEM. 

is flattened and the greatest diameter is across the temples. The 
head may attain an enormous size, the child being unable to hold it 
upright. The hair is scanty and dry. There may be strabismus, 
palsies, contractures, and convulsions. The eyes may not be on a 
level. Blindness may result. When the disease is progressive, 
idiocy develops. The children are very weak. 

Diagnosis. — Hydrencephaloid or spurious hydrocephalus is a con- 
dition which supervenes in acute exhausting states, such as that which 
follows diarrhoeal diseases. There is neither bulging of the fonta- 
nelles nor enlargement of the head. The fontauelle is depressed 
and the eyes are sunken. In certain forms of rachitis which are 
accompanied by craniotabes and cranial bosses over the parie- 
tal and frontal bones, there is frequently a very mild form of 
hydrocephalus. This condition is rarely progressive. It may be 
distinguished from true congenital hydrocephalus by the absence 
of progressive enlargement of the skull. The sutures may be 
patent, especially that between the parietal and frontal bones. The 
signs of rachitis are present elsewhere, and the children are, in 
contrast to the semi-idiotic subjects of hydrocephalus, very bright. 

In differentiating internal congenital hydrocephalus from the 
external form, the history is of great value. External hydro- 
cephalus appears at birth and is not accompanied by bulging of the 
frontal and occipital bones. Mental deficiency is present from the 
outset. Late in the disease it may be impossible to distinguish 
between the two forms. A form of cranial syphilis is mentioned by 
Gowers as causing cranial enlargement, which, however, is never so 
marked as in congenital hydrocephalus. 

The diagnosis of congenital chronic internal hydrocephalus rests 
on the progressive enlargement of the cranium, the bulging in the 
occipital and frontal regions, and the flattening across the lambdoid 
suture. Acquired hydrocephalus rarely appears before the tenth 
month (Ireland). 

It is sometimes of interest to distinguish at autopsy between the 
congenital and acquired forms of hydrocephalus. Meynert has shown 
that in congenital hydrocephalus the lateral ventricles are dilated in 
their long diameters ; the posterior horn is dilated, so that it reaches 
within a few millimetres of the cranium. Acquired hydrocephalus, 
on the contrary, usually dilates the ventricles in their vertical and 
cross diameters. 

Prognosis. — Hydrocephalus is one of the most fatal nervous 
affections. There are mild forms in which the accumulation of 
fluid ceases after a certain time and recovery takes place, the intelli- 
gence being either slightly weakened or normal. In some cases the 
enlargement continues and death ensues from marasmus. In other 
cases the head becomes of enormous size ; the increase of fluid ceases ; 
the fontanelles and sutures close ; the unfortunate subjects have an 



EXTERNAL HYDROCEPHALUS. 503 

enormous ossified skull, which they are unable to hold upright. 
They are partially idiotic or imbecile. They often, however, have a 
slight degree of intelligence, and may recite lessons, but are helpless 

in every way. 

The treatment of congenital internal hydrocephalus is alone of 
interest to the physician. The condition is hopeless. The injection 
of solutions of iodine (Morton's fluid) has been tried with doubtful 
results. I have had 2 cases in which the ventricles were aspirated, 
fluid was withdrawn, and the head bandaged. The operations were 
performed by an expert under antiseptic precautions. In neither ease 
was the course of the disease affected. The fluid reaccumulated. 
Both patients died. On another infant, I performed repeated lum- 
bar puncture at intervals of weeks. The infant seemed brighter after 
each operation. Several days after the last puncture the temper- 
ature rose to 108° F. (42.2° (Y), Cheyne-Stokes respiration set in, 
and the patient dial. 

Cases in which Keen, of Philadelphia, inserted a permanent 
drain did not give encouraging results. Pott had an equally dis- 
couraging experience with that mode of treatment. Iodide of potas- 
sium administered internally is of doubtful value. In estimating 
the results of treatment, it should not be forgotten that a small 
percentage of eases cease to progres> at a certain stage of the disease, 
and make a tolerably fair spontaneous recovery. 

External Hydrocephalus. 

External hydrocephalus may be acquired or congenital. If 
congenital, it follows an intra-uterine pachymeningitis or may take 
place because of the rudimentary state of the cerebrum (hydro- 
cephalus anencephalique). External hydrocephalus may be ac- 
quired, in which case it follows a pachymeningitis internal hemor- 
rhagica <>r i- the result of a meningitis in infancy. I have seen 
such cases. The congenital form of external hydrocephalus is very 
rare. Bokai records a case in an infant nine months of age. There 
was an accumulation of fluid between the dura and the pia mater. 
Both membranes and the falx were thickened, but there were other- 
wise no signs of inflammation. The infant had spastic symptoms. 
The diagnostic points in these cases are the uniform enlargement of 
the head and the bulging, especially in the temporal region. The 
axe- of the eye- remain normal, the condition of those organs dif- 
fering in that respect from that seen in internal hydrocephalus, 
in which they are depressed downward. There may be slight 
exophthalmos. In Lewi- Smith's case, the axe- of the eyes were 
normal. 

In some cases of external hydrocephalus the head attains an 
enormous size. The disease cannot then be distinguished from the 



504 DISEASES OF THE NERVOUS SYSTEM. 

chronic internal form. In one of my cases external hydrocephalus 
followed meningitis. The head was uniformly large, the bulging 
over the temporal region being marked. The axes of the eyes were 
normal. The intelligence was low. 

In some cases of external hydrocephalus there is a slight internal 
hydrocephalus. 

AMAUROTIC IDIOCY. 

( Family Idiocy — Sachs.) 

This disease was first described by Warren Tay, an English 
oculist, in 1881. Among other symptoms, he noticed peculiar 
changes in the fundus of an infant suffering from the affection. We 
owe the more extensive study of the affection to the American neu- 
rologist Sachs, who described his first case in 1887, not knowing 
that Tay and Kingdon had previously published theirs. Sachs has 
collected 27 cases in the literature, his ow r n cases being included in 
the number. I have published 2 cases and have since seen 6 others. 

The etiology of the affection is still unknown. Alcoholism and 
syphilis do not appear to be very closely connected with its occur- 
rence. It appears to run in ' families. Frequently two or more 
children in a family are affected. 

Morbid Anatomy. — Tay-Kingdon, Sachs, and Yan Giesen 
have studied the changes which occur in the nervous system. The 
cases of Sachs were examined by Van Giesen, who found that the 
ganglion-cells of the cortex of the cerebrum, and especially the 
pyramidal cells, showed changes which indicated an arrest of de- 
velopment — an agenesis corticalis. There were no changes in the 
ganglion-cells of the cord and nuclear masses. There were degen- 
erative areas in the white matter of the lateral tracts. Hirsch has 
lately examined, by new methods, the brain and cord in a case 
of amaurotic idiocy. He found a uniform degeneration of the 
ganglion-cells of the gray matter throughout the whole nervous sys- 
tem. There were chromatolysis and displacement of the nuclei of the 
ganglion-cells toward the periphery of the cell-body, with a destruc- 
tion and breaking off of the dendrites and axis-cylinders. These 
changes were found throughout the gray matter of the brain and 
spinal cord. Hirsch thinks that these changes support his theory of 
the toxic nature of the disease. He is inclined to regard amaurotic 
idiocy as a form of infection originating in the intestinal canal. 

The symptoms are divided as follows : (1) Psychical disturb- 
ances tending to complete idiocy. (2) Weakness, resulting after a 
time in complete paralysis. (3) A normal, diminished, or increased 
state of the deep reflexes. (4) Increasing blindness with pathogno- 
monic changes in the region of the macula lutea (Tay and Kingdon' s 
spot), with optic neuritis. (5) Marasmus. 

The history of all the cases is practically the same. The infant 



TUMORS OF THE BRAIN. 505 

is normal at birth. After from two to eight months, it is found to 
be indifferent to its surroundings. It rolls the eyes here and there. 
Although well nourished, it cannot sit up or hold the head upright. 
The head falls backward when an attempt is made to cause the 
infant to sit upright. Many of the infants cry constantly, at the 
same time making automatic facial grimaces. The lower extremities 
are weak and may exhibit complete paralysis (diplegia). In other 
eases, there may at intervals be a spastic rigidity of the lower extremi- 
ties, alternating with a lax condition. Convulsions are absent or 
may occur occasionally. The deep relaxes may be normal or dimin- 
ished. In the spastic cases they are increased. After the first year 
the infants become totally blind and completely idiotic. They finally 
become marantic, and die after the second year with the symptoms 
of advanced infantile atrophy. Occasionally there are nystagmus, 
strabismus, and hyperacusis. Deafness supervenes in many cases. 
The electrical contractility of the muscles may be normal or, as in 
one of my* cases, diminished. 

Ocular Changes. — The changes in the fundus of the eye described 
by Tay and Kingdon have been confirmed in the cases of Sachs, 
Koller, Heiman, and in my cases. They are invariably present at 
some period of the disease, but may only appear late, as in the 

is of Koller. Once present, they fix the diagnosis absolutely. 
The appearances consist of a cherry-red spot on a diffusely white 
area at the region of the macula lutea. I have seen 8 cases in which 
they were present. Optic neuritis is also present toward the. close 
of the disease. 

Diagnosis is not difficult after a study of the symptoms. If 
an infant is brought to the physician with a history of good 
health and intelligence up to a certain time, after which weak- 
liest and loss of interest in its surroundings set in, with inabilitv 
to hold the head upright, the fundus of the eye should be examined. 
If Tay-Kingdon's spot is found, the diagnosis is fixed I have 
lately -ecu a number of cases in which the spastic symptoms were 
predominant. There were idiocy, increase of reflexes, complete or 
total blindness, and hyperacuitv. I have watched infants with 
these symptoms for a long time and failed, even with expert aid, to 
find Tay-Kingdon's spot. In these cases there was probably a 
birth palsy. 

The prognosis is invariably fatal. Of the 27 cases of Sachs, 
only 1 lived to the age of six years. Most of the infants die before 
the end of the second year 

TUMORS OF THE BRAIN. 

Fully 50 per cent, of the brain tumors in infancy and childhood 
are tuberculous ; gliomata and sarcomata are next in order of fire- 



506 DISEASES OF THE NERVOUS SYSTEM. 

quencv. Cysts are secondary to a hemorrhage or embolism. They 
may remain stationary for a long period, and then increase in size 
and cause symptoms. Males are affected twice as frequently as 
females ; two-thirds of the cases in male subjects are cases of gliomata 
and tubercle. Tumors are rare in the first six months of life. The 
largest number occur in the first decade. 

Location. — The medulla is rarely the seat of tumor. The cere- 
bellum is most frequently involved (50 per cent, of the cases, Ger- 
hardt, Peterson). The pars centrum ovale and basal ganglia are 
the parts next most frequently affected. 

Etiology. — The role of traumatism is not clearly understood. 
Gliomata are due to a proliferation of the neuroglia. Tubercle and 
sarcomata are secondary to foci elsewhere. Carcinoma is rare. In 
some cases of that growth the orbit is a focus of infection. 

Symptoms — Symptoms of pressure and irritation vary with the 
location of the tumor. A small but rapidly growing tumor will 
cause more pronounced symptoms than a large tumor of slow growth. 
Interference with the blood-supply and an increase in the quantity 
of fluid within the ventricles of the brain will cause the symptoms 
to vary. 

General Symptoms. — Headache. — This may in cortical and 
meningeal tumors be intense. It is of a boring, gnawing character, 
and is referred to the region of the tumor. Tumors in infants may 
attain great size previous to ossification of the skull. The bones 
of the skull are pushed apart and the sutures opened up. There 
is very little pain. Sleeplessness and restlessness, emaciation, and 
cerebral excitement are marked. 

Xausea and vomiting are prominent symptoms and persist for 
a long time. The vomiting is projectile and occurs independently 
of the ingestion of food. 

Vertigo is common and occurs with every change in the position 
of the head. It is a common symptom in tumors of the pons and 
cerebellum. 

Convulsions. — These may be localized or general. They occur 
when the cortex and motor areas are invaded, and eventuate in epi- 
lepsy of the Jacksonian type. In this form of epilepsy, the attack 
begins in the head or arm corresponding to the area of irritation, and 
subsequently becomes general. 

Optic neuritis and optic atrophy are important symptoms of 
intracranial tumor, but are not always present. When tumors are 
situated at the base of the brain, the symptoms appear early and are 
due to pressure on the chiasm. Optic neuritis is either double or 
more pronounced in one eye. 

The pulse and respiration present no characteristic features. 
They show irregularities in rate. Respiration is affected only toward 
the close of the affection. 



TUMORS OF THE BRA IX. 507 

Symptoms Dependent on the Location of the Tumor. — Cortical 
tumors in or near the motor areas cause convulsive seizures, 
which occur from the outset. Subcortical tumors will at first 
cause paralysis and, as they encroach upon the cortex, convulsions. 
With invasion of the cortex there are, in addition to convulsions 
with subsequent epilepsy, intense headaches. Tubercle, glioma, 
and gumma occur near the surface. Cysts and sarcoma are more 
deeply situated. 

The Frontal Lobe. — The tumors situated in this region cause 
stupidity and other marked changes in the degree of intelligence. 
There will be a perversion of the sense of smell, salivation, and also 
the drooling seen in idiocy. If the third frontal convolution is af- 
fected, there will be motor aphasia associated with agraphia — a rare 
condition in childhood. Tumors of the motor area will in the earlier 
stages cause cortical irritation, manifested in convulsive twitchings 
in the parts first paralyzed. There may be slight sensory or motor 
disturbances in an upper extremity and an occasional twitching of 
the arm, forearm, or thumb. 

The tumors of the parietal lobe cause sensory changes in 
the limbs of the opposite side of the body (Dana). If the white 
substance is the seat of tumor, there may be hemianopsia ; Wernicke's 
centre for conjugate movement of the eyes may be affected if the 
tumor is situated in the inferior part of the parietal lobe. 

Tumors of the occipital lobe cause homonymous hemianopsia 
with or without epileptiform convulsions, the latter being probably 
due to invasion of the cortex. 

Tumors of the temporospiiexoidal lobe cause impairment of 
hearing on the side opposite to the lesion and sensory aphasia. The 
patient is able to speak, but cannot understand what is said or repeat 
spoken language. 

In tumors of the GANGLIA, there i> involvement of the internal 
capsules. There are no convulsions and none of the choreic and 
athetoid movement seen in cortical tumors. 

Tumors of the crus CEREBRI cause paralysis of motion and 
sensation on the opposite side of the body, and oculomotor paralysis, 
ptosis, and paralysis of the muscles of the eyeball, except the exter- 
nal rectus and superior oblique. There will be paralysis of the 
sphincter iridis and ciliary muscle. There may be paralysis of both 
-ides of the body, double ptosis, and double oculomotor symptoms. 
The majority of cases are at first unilateral, later becoming bilateral. 

- of pupillary reflex, nystagmus, and cerebellar ataxia point to 
involvement of the corpora quadrigemina. 

Tumors of the pons cause unilateral or bilateral symptoms. 
Then- i> hemiplegia or double hemiplegia with paralysis of the 
cranial nerve-. There i- paralysis of the third, fifth, sixth, sev- 
enth, and eighth nerve- of the side of the lesion, with hemiplegia of 



508 DISEASES OF THE NERVOUS SYSTEM. 

the opposite side. There may thus be paralysis of the external rectus 
with facial palsy and impairment of hearing on one side. If the 
nucleus of the sixth nerve is involved, there will be paralysis of con- 
jugate movement of the eyes toward the side of the lesion, while if 
it is not affected there will be only external rectus palsy of the side 
of the lesion not affecting conjugate movement of the other eye. 

Tumors of the medulla manifest themselves in bulbar symp- 
toms. There will be paralysis of the glossopharyngeal, vagus, 
spinal, accessory, and hypoglossal nerves. Thus there are unilateral 
or bilateral paralysis of the arms or legs, difficult deglutition, and 
disturbances of the respiratory movements and of cardiac action. 
In addition there will be spasm of the sternomastoid and trapezius 
muscles, and paralysis of the tongue, with atrophy, vomiting, poly- 
uria, and glycosuria ; optic neuritis occurs early, and there is severe 
occipital headache. Gummata in this region are not uncommon. 

Tumors of the cerebellum, which are usually of the solitary 
tuberculous form, are the most important intracranial growths in 
children. There will be occipital headache, vomiting early in the 
disease, and cerebellar titubation due to encroachment upon the 
middle peduncle. Vertigo is severe. The sixth, seventh, or eighth 
cranial nerves may be involved. There may be bulbar symptoms. 
Paralysis of the external rectus is very common in these tumors. 
Optic neuritis may be present. 

This list is by no means complete. The notes are given as 
concisely as possible. For further details the student is referred 
to the extensive monographs on Tumors of the Brain. 

INFANTILE CEREBRAL PALSY. 

(Spastic Hemiplegia; Diplegia: Paraplegia.) 

Forms. — All clinicians of note now classify these palsies with 
regard to the time of onset. There are three varieties — the intra- 
uterine or prenatal, the birth palsies, and the post-natal forms. 

Brain palsy is a common disease of infancy and childhood, and 
has been known to occur up to the tenth year. Gowers and 
Osier are agreed that these palsies are most frequent in the first two 
years of life. They occur with equal frequency during the first and 
second years. 

The etiology of the affection is still very obscure, and differs in 
the various forms. In the intra-uterine or prenatal form, the causal 
influences are especially indefinite. The influence of maternal im- 
pressions, such as fright or worry, is uncertain. Other causes fre- 
quently cited are hereditary insanity or neurotic affections, an injury 
or blow to the abdomen, exhausting fevers during pregnancy, pneu- 
monia, typhoid fever, and ursemic convulsions. The rdle played in 



INFANTILE CEREBRAL PALSY. 509 

this disease by syphilis is as yet undetermined. That of alcoholism 
is also obscure. 

The birth palsies have been studied by Little and McNutt. To 
the latter we owe the tirst lucid post-mortem demonstration of their 
cause. She published several eases under the title of Apoplexia 
Neonatorum. It was demonstrated in this article that in easy 
labors as well as in prolonged and instrumental deliveries, hemor- 
rhages on the surface of the brain occurred and were the cause of 
subsequent palsies, with the resulting contractures and idiocy seen 
in such eases. 

The Post-natal Cases. — The etiology of these cases is still a matter 
of discussion. When Strumpel proposed the theory of an enceph- 
alitis similar to that occurring in infantile poliomyelitis, it was for a 
short time accepted. Clinically this theory was founded on cer- 
tain similarities between the spinal and cerebral affections. It has 
since been abandoned. It is found that many of the cases follow 
the acute infectious diseases, especially measles and scarlet fever 
(Growers). Cerebral palsy may follow typhoid fever, pertussis, 
pneumonia, amygdalitis, cerebrospinal meningitis, gastro-enteritis, 
and traumatism to the skull. Infection or the presence of infec- 
tious disease cannot alone explain all the cases. The view most 
generally accepted is that the convulsion at the outset of the dis- 
ease causes the bursting of a vessel weakened by some form of 
degeneration (Osier). 

Morbid Anatomy. — Prenatal Cases. — There is porencephaly. 
Half a hemisphere, an entire hemisphere, or both hemispheres may 
be imperfectly developed. There are also certain defects in the cere- 
bral hemisphere to which is applied the term " Agenesis Corticalis." 
That is to say, there is imperfect development of the cortical gray 
cells, particularly those of the pyramidal type. The agenesis may 
extend throughout all parts of the hemispheres 

Birth Palsies. — The principal lesion is meningeal hemorrhage 
(McNutt). This may occur in areas over the cortex, or at the base 
of the brain. There may be a diffuse hemorrhage over the whole 
cortex of one hemisphere. The extravasation is, as a rule, most 
profuse over the motor area. 

Acute Palsies. — In these, there are found embolism and throm- 
bosis, or hemorrhage, the latter occurring mostly at an advanced age. 
As a result there may be atrophy of the cortex, sclerosis or cyst 
formation-. Cysts arc sometimes found later in life, there having 
been no previous symptoms (Gowers), They undoubtedly origi- 
nate in infancy. Some authors (Growers) state that embolism, 
others that hemorrhage, is the pathological condition most frequently 
found in cerebral palsies of acute origin. The cause of hemorrhage 
in these cases i- -till a matter of -peculation. There is certainly a 
change in the bloodvessels, but whether it is the fatty change seen 



510 DISEASES OF THE NERVOUS SYSTEM. 

in the bloodvessels in infancy and first pointed out by von Reck- 
linghausen, is a question. It may be that, given a vulnerable 
bloodvessel, heart disease or any infectious disease will predispose 
to hemorrhage. Cysts are likely to be found in cases in which 
there is idiocy. 

Symptoms. — In the prenatal cases the infant is born with the 
disease partially or completely developed. There are cases in which 
no symptoms are seen at birth. They develop during the first 
year. 

Birth Palsies. — In these cases, as in those of McNutt, there are 
symptoms of hemorrhage, disturbance of respiration, partial or 
complete loss of consciousness, and convulsions which may be 
general, or involve only one side of the body. The majority of 
infants thus affected die soon after birth ; others live to exhibit 
various symptoms of defective development of the brain. There 
are paralyses more or less complete, with contractures, spastic 
rigidity of sets of muscles or of all the muscles, and increase of 
tendon reflex. 

The clinical history of the very mild forms of cerebral birth 
palsy is characteristic. Many of the cases are mistaken for cases 
of asphyxia neonatorum. After a normal delivery, the infant is 
noticed not to breathe deeply or regularly and to appear at times to 
cease breathing. If roused, it cries feebly, but again relapses into a 
quiescent state, the breathing being irregular and shallow. It 
becomes slightly cyanosed, and while in this state may have re- 
peated convulsions. In other cases the infant is born apparently 
well, but after twenty-four hours the respirations become shallow 
and increase in frequency, and convulsions appear. These cases may 
recover. At about the time when the infants attempt to walk they 
may show slight spastic symptoms in the lower extremities, and have 
overextension of the foot and toes as soon as any attempt is made 
to place the feet on the ground. 

In severe cases unilateral paralysis and weakness of the muscles 
which support the head remain permanent. Spastic and paralytic 
symptoms are in some cases very marked. Athetoid movements 
of the extremities, with inability to grasp objects, contractures of 
the lower extremities, adduction of the thighs, mental defects, 
inability to sit upright, and oscillation in walking complete the 
later picture. 

Acuto Cerebral Palsy. — According to Gowers, the onset is acute in 
two-thirds of the cases occurring before the end of the second year. 
The condition occurs with the same frequency in the first and second 
years, and is as a rule primary (Gowers). Although, as has been 
stated, it may follow the infectious diseases, there are frequently 
no premonitory symptoms ; the patient retires in good health and 
awakens with a hemiplegia. In more than half the cases the disease 



INFANTILE CEREBRAL PALSY. 511 

is ushered in with convulsions, generally unilateral. Whether these 
are present or not, there is unconsciousness lasting a few hours or 
for days, and sometimes fever and vomiting. When the child 
recovers the hemiplegia may be complete or the paralysis may develop 
slowly. The right side is more often involved (Osier). 

The symptoms in order of occurrence are as follows: 

Convulsions. — Coma and convulsions may he present at the outset, 
hut may not develop until later in the disease. They are most 
likely to occur at the outset of the infectious diseases. If they per- 
sist into the later periods, epilepsy is likely to develop. I have 
seen a case in which as many as forty convulsions of an epileptiform 
character occurred daily. A condition of weak-mindedness or com- 
plete imbecility supervenes. Many of these eases are mistaken for 
true epilepsy. 

Paralysis. — In all forms of cerebral palsy, there may be hemi- 
plegia, diplegia, or paraplegia. As a rule, hemiplegia is of the right 
side (Osier). The facial muscles of the same side may be involved. 
There may be no facial paralysis. Monoplegia, especially of the 
leg, is rare. Diplegia is not common. After a time, contractures 
of the extremities occur. With these changes, there are charac- 
teristic disturbances of motion. There is the gait of the 
hemiplegic, slightly or markedly developed. As has previously 
been stated, the children may be born with contractures. A 
spastic paraplegia with athetosis in the upper extremities indicates 
the possibility that the arm may have been involved earlier in the 
disease. In about 20 per cent, of the cases, the face is involved 
at the outset. Motor aphasia is present. It is not present in birth 
palsies. According to Freund, hemianopsia is occasionally present. 

Disturbances of sensation are rare. 

Reflexes. — The deep reflexes are increased. There is no atrophy 
of the muscles as in infantile spinal palsies, or it is at most slight. 

With the ataxia, there are the athetoid movements first 
described by Hammond. These are sometimes marked. In some 
cases, there are cataleptic phenomena. In all cerebral palsies of 
whatever origin, paralysis, rigidity of muscles, contractures, and 
increase of the deep reflexes are constant features. 

Diagnosis. — Intra-uterine and birth palsies give a distinct his- 
tory of early development. If a palsy has developed a few months 
after a normal labor, it is to be classed as possibly intra-uterine. 
Both prenatal and birth palsies are likely to be diplegic or para- 
plegic. A- a rule there is mental deficiency. Paralysis may be 
complete, or, a- in one of my cases, scarcely noticeable. Double 
athetosis ifl indicative of double hemiplegia, and may even take the 
place of paralysis. Choreiform movements are frequently mistaken 
for chorea. They are unilateral and combined with exaggerated 
reflexes and partial, slight or marked paralysis. Aphasia of eerebral 



512 DISEASES OF THE NERVOUS SYSTEM. 

palsies is motor rather than sensory. Its presence precludes the 
possibility of the palsy's being of prenatal or of birth origin. 

The cerebral palsies are differentiated from the infantile forms of 
paralysis by the presence of contractures, rigidity, increase of deep 
reflexes, and occasionally by the presence of athetosis and chorei- 
form movements. In recent cases the absence of atrophy will also 
aid in diagnosis. 

Prognosis. — So far as prenatal and birth forms of palsy are con- 
cerned, no definite prediction in regard to the outcome can at first 
be made. Many of the cases of birth palsy die at the outset. Some 
escape with very slight paralysis. Others develop convulsions with 
subsequent epilepsy and idiocy. Contractures, diplegia, and double 
hemiplegia with spastic symptoms may develop. The acute cerebral 
forms may improve to such an extent that only slight paralysis, 
choreiform movements, or athetosis remain. In other cases im- 
provement is followed by a return of the symptoms, with convulsions 
and epilepsy. It is estimated that fully 45 per cent, of the cerebral 
palsies develop epilepsy, while the diplegic forms are less likely to 
do so. One convulsion is apt to be followed by others, and these 
in time by epilepsy and mental deficiencies. 

The treatment of cerebral palsy is ultra-conservative. Cases 
of birth palsy have difficulty in deglutition. Aid in keeping up the 
nutrition of the patient may be given by spoon-feeding or feeding 
with stomach-tubes (gavage). If there are convulsions, bromides in 
moderate doses are administered. The infant should be kept per- 
fectly quiet. In the acute cerebral cases, if hemorrhage is suspected 
rest and the application of an ice-bag to the head are indicated. 
Subsequent convulsions are treated with bromides. The bowels are 
kept open with calomel. In cases in which there is slightly 
marked paralysis, massage and the various forms of hydrotherapy 
are of great utility. The faradic current has much the same effect 
as massage. If contractures and choreiform movements supervene, 
the various orthopaedic appliances are of great practical utility. 
Where indicated, they should be used in connection with judicious 
tenotomy. Surgical interference has been practised in forms of epi- 
lepsy which simulate the Jacksonian type. The results are disastrous 
in young children, nor is permanent relief to be expected in older 
ones. 

FACIAL PALSY. 

{BelVs Paralysis.) 

Paralysis of the facial nerve is quite common in infancy and 
childhood. As in the adult, the distribution and etiology of the 
paralysis vary. 

The facial paralysis observed in infants who have been delivered 



FACIA J. PALSY 



513 



with forceps is a pressure paralysis. Tt may affect the upper or 
lower branches of distribution. The prognosis of this form of paral- 



FiG. 143. 




Facial paralysis, left side, rheumatic form. Girl, eight years of nge. 
Fig. 144. 




Facial para! latic f >rm, showing inability to close the eye. Girl, eight years- of age. 

ysis is, as a rule very good. Recovery takes place after a few 
weeks. Borne cases do not thus recover; there should therefore 



514 DISEASES OF THE NERVOUS SYSTEM. 

be some conservatism in prognosis. Congenital facial palsy may. 
occur in the absence of any history of traumatism or pressure. 
Henoch records such a case in a boy of ten years. There was' 
deafness on the side of the paralysis, but no history of disease of 
the ear. 

The so-called rheumatic form of facial paralysis occurs in infants 
and children, but rarely does so before the third year, and most 
commonly between the sixth and fifteenth years. The symptoms 
are the same as in later life (Figs. 143 and 144). 

Of greatest interest to the practitioner are the facial palsies 
which occur in infants and children as a result of ear disease or of 
inflammatory disease of the mastoid process. In infants a few 
months old, I have seen facial palsy due to otitis in one ear 
(Fig. 145). Henoch has seen cases in infants from three to five 

Fig. 145. 



Facial palsy complicating otitis. Infant, seven months of age. 

months of age. The facial nerve is affected as it passes through 
the Fallopian canal. Caries of the bone, pus, or swelling in 
the vicinity of the canal, will cause this form of paralysis. It is 
therefore a species of pressure paralysis. There may be no dis- 
tinct collection of pus in the mastoid cells, but, when opened 
up, the mastoid is found to be filled with granulations. Tem- 
perature, tenderness, and redness over the mastoid should arouse 
suspicion. 

Bokai reports a case of retropharyngeal abscess in which the 
facial palsy was caused by pressure on the nerve as it emerged from 
the stylo-mastoid foramen. 

Another form of facial palsy is that seen in basilar disease of 
the brain. The facial palsy seen in tuberculous meningitis and 
sometimes in the non-tuberculous variety is of great diagnostic 



MULTIPLE NEURITIS. 515 

import This paralysis is not always marked ; it is often a very 
slight paresis with flattening of the facial muscles on one side and 
accompanied by Blight widening- of the palpebral fissure on the same 
side. In connection with this symptom, a dilatation of one pupil or 
slight strabismus is exceedingly significant of basilar affection. In 
other words, in the forms o\' meningitic facial palsy, the physician 
should he on the alert for changes in the contour of the face, since 
in many of these cases the patient is conscious only at intervals. 
In many cases, restlessness on the part of the patient will cause 
the slight flatness of the face or widening of the palpebral fissure to 
disappear. The patient should be watched unawares or when at 
perfect rot. The facial palsies with cerebellar tumors and tumors 
of the pons have been referred to in the section on Tumors. 

Operative facial palsy in infants and children is likely to occur 
after the radical operation on the mastoid, if the operator is not a 
thorough anatomist. I have felt that this accident could be avoided. 
After an operation on the mastoid I have seen mild facial palsy, 
consisting of a very slight lagophthalmos with slight flattening of 
the facial muscles, which disappeared within twenty-four hours. It 
was possibly due to pressure on the nerve during the operation. 
Facial palsy following a mastoid operation is, as a rule, due to 
actual traumatism to the nerve, and to its partial or total destruc- 
tion. The paralysis in such cases is permanent. 

The treatment of facial palsy in infants and children is deter- 
mined by the origin of the palsy, and is essentially the same as in 
the adult. 

MULTIPLE NEURITIS. 

This is an affection in which several or most of the peripheral 
nerves undergo degeneration of an acute type. The nerves affected 
are, as a rule, symmetrically distributed. 

Etiology. — The disease may be caused by the poisonous action 
of drug-, such a- lead, arsenic, and alcohol. It follows the infectious 

disease measles, diphtheria, typhoid fever, influenza, and malaria. 

In such cases the degeneration is due to the action of bacterial 
toxin- on the peripheral nerve-. Cold i- -aid to favor the onset of 
the disease. In many cases, it is impossible to fix upon any 
definite cause. 

Morbid Anatomy. — There is an early stage during which there 
are hyperemia and -welling of the -heath- of the nerve-, which may 

be the -cat of minute hemorrhages. The nuclei of the sheaths are 

enlarged. There is an increase of connective-tissue cells between the 

nerve— heath-, and also of round and spindle-shaped Cells between 

the nerve-fibres. The changes in the aerve-fibres .ire characteristic 
of nerve degeneration. The muscles may be the -eat of parenchy- 



516 DISEASES OF THE NERVOUS SYSTEM 

matous degeneration. The striation may become indistinct. In 
some cases there are also interstitial changes. 

The symptoms of multiple neuritis in children are very charac- 
teristic. After an infectious disease, the child no longer walks with 
a steady gait, but may stumble and fall. After a time it is noticed 
that the patient does not care to stand, and the mother is unable to 
persuade it to do so. The child cries when put on its feet, which 
refuse to support it. There seems to be pain connected with an 
attempt to stand, and also on handling and pressing the muscles. 
After a time the child does not sit upright, but falls back or toward 
one side when put in the sitting posture. It finally becomes 
completely paralyzed. The paralysis is progressive and symmetrical. 
The child does not use the hands. The feet drop forward (foot- 
drop) and there is a very characteristic wrist-drop. The child lies 
helpless in the crib, unable to move. Some of these patients cry 
constantly as if in pain. During this time there is good nutrition 
and the appetite is good. The muscles of the trunk are frequently 
affected as Avell as those of the extremities. In these cases there is 
a species of paralytic lordosis when the child stands or sits upright. 
In a few cases the muscles of the eye are affected, and in fatal 
cases those of the diaphragm. 

The facial and hypoglossal nerves are rarely the seat of the dis- 
ease. The musculospiral and peroneal nerves seem, as in polio- 
myelitis, to be affected. The reflexes are diminished and finally 
disappear. The dorsum of the feet and hands is slightly affected 
with oedema. 

Sensory Disturbances. — In spite of statements to the contrary, 
it is very difficult in children and infants to elicit exact data as 
to the pain or sensory changes and their distribution. I have 
found evidences of pain on handling the children or attempting 
to make them stand or sit. The patients are restless at night, 
and cry most of the time, and it must therefore be inferred that 
they have pain. 

Course. — The majority of the cases make a complete or almost 
complete recovery. In a case which I watched very closely the 
reflexes were slow to return, although the child began to sit upright, 
then to stand, and finally to walk. The gait in walking was very 
peculiar. It was a sort of waddle, resembling that exhibited in 
congenital luxation of the hips. The boy, three years of age, 
finally made a complete recovery. 

As a rule, the symptoms increase in severity for from four to six 
weeks ; they then retrograde and improvement sets in. In some 
cases the development of symptoms is rapid, the diaphragm becomes 
affected, and the children die of bronchopneumonia. If the vagus 
is affected, death occurs through cardiac failure. 

Diagnosis. — If the clinical picture is studied, the diagnosis is 



MULTIPLE NEURITIS. 



517 



not difficult. The complete and absolute paralysis is, in its mode of 
onset and its symmetrical distribution with anatomical impairment 
of sensation of all kinds, so peculiar that it cannot be confounded 
with poliomyelitis. In the cases which I have seen, the muscular 
atrophy was also less marked than in the latter disease. The very 
characteristic feature of the paralysis is its flaccidity. If the child is 

Fig. 140. 




Multiple neuritis in a child two and one-half y<-ar- of ncrr. shows the complete relaxation 
of the glutei in'; tvery. 

made to .-it upright, the glutei muscles Hare, as it were, outside the 
body-line and do not retain the tonicity of the normal muscle. 
There is nevertheless not much atrophy of the glutei. Landry's 
paralysis is so rare in infancy and childhood that it need not be 
considered in detail. 

The treatment is palliative, since the disease is not only self- 



518 DISEASES OF THE NERVOUS SYSTEM. 

limited, but also tends to spontaneous recovery. The pain is 
relieved and the skin kept in good condition by massage. If the 
child is restless, it is treated in the ordinary way. There is no 
specific for the affection. Electricity is not recommended by those 
whose experience gives weight to an opinion. If contractures result, 
orthopedic appliances are indicated as in other paralytic diseases. 



ERB'S PALSY. 

( Obstetrical Palsy.) 

This form of palsy, which occurs in infants and children as well 
as in adults, is due to a neuritis caused by direct traumatism either 
to the nerves supplying the muscles of the shoulder, or as in the 
newly born infant by traction or pressure on the brachial plexus 
(see Fig. 27). Erb showed that the point injured in these cases 
is the spot between the scaleni at the exit of the fifth and sixth 
cervical nerve roots. Duchenne, Seeligmuller, and Henoch have 
described these birth cases in infants. I have seen cases in older 
children which correspond to the adult cases. 

The symptoms are very characteristic. There is complete 
paralysis of the arm on the affected side. The child, if directed to 
raise the arm or forearm, is unable to do so. The fingers can be moved. 
Infants sometimes hold the paralyzed arm with the healthy one. In 
a few cases there seems to be pain, caused by the drag of the para- 
lyzed member on the shoulder. After a time there is atrophy of the 
deltoid and other muscles about the shoulder-joint, which causes the 
bony prominences to show markedly (Plate XXL). The atrophy 
sometimes comes on very rapidly. In infants and children it is 
impossible to reach any conclusion in regard to the intensity of pain 
and the disturbances of sensation. 

The cases should be differentiated from cerebral birth palsies. 
Apart from the electrical reaction, the absence of hemiplegia or 
diplegia of a spastic nature with rigidity, the absence of increased 
reflex, and also of convulsions, all of which are present in birth 
palsies, will aid in the diagnosis. Later in life it may not be possi- 
ble to determine which form is present. 

The prognosis is good, but I have seen severe cases of obstetrical 
palsy which failed to recover. 

The treatment depends on the origin of the palsy. If it is 
obstetrical, the arm should be put in an apparatus to protect it from 
injury. After two weeks, friction, massage, and a mild electrical 
current of the faradic variety should be applied. If contractures 
develop later, splints should be constructed to counteract the ten- 
dency. On the whole, the management of the cases is based on the 
principles which govern the treatment of peripheral palsies. 



PLATE XXI 




Erb's Paralysis in a child twenty-six months of age. 
Atrophy of the deltoid, subluxation of the arm; bony 

prominences mark 



HER KDITARY A TAX I A . 519 

HEREDITARY ATAXIA. 

{Friedreich's Disease; Hereditary Ataxic Paraplegia.) 

This is a form of ataxy which frequently affects several members 
of the same family. Rutimeyer and Griffith collected 233 cases 
which were distributed in 1 07 families. In 38 cases there was a 
direct hereditary history. In the remainder, there was a history of 
alcoholism, syphilis, or consanguineous marriage. Sixty-five cases 
of Growers were distributed among 1!> families. Tims there was an 
average of 3 to each family. In some families there were 10 cases. 
[solated cases are rare, and occur, as a rule, only in children. The 
disease affects the sexes equally. Cases have occurred as early as the 
-ccoiid \car, and as late as the twenty-fourth, but are seen most fre- 
quently between the seventh and eighth years. 

Symptoms. — The onset of the disease may be gradual or abrupt. 
The first symptom i- an impairment of coordination in the lower 
extremities. The patient is unsteady in walking, and stands with 
the feet wide apart Some patients reel when the eyes are closed 
more than at other times. In other cases Romberg's symptom is 
absent. The feet show the peculiar deformity of pes cavus. The 
instep i- high and the toes overextended. The movements of the 
arm- next become ataxic. The speech becomes slow and halting. 
Jerking, nodding movements of the head set in. Irritability of 
muscle is absent from the beginning. The deep reflexes may be 
present at Brst, but finally disappear as in true tabes. 

Nystagmus i- usually present, and may be a very early symptom, 
appearing simultaneously with the ataxic symptoms. The symp- 
tom- connected with the speech may come on very late in the disease. 

Optic atrophy i- never present, and the Argyll-Robertson pupil 
of tabes is absent. 

Sensory disturbances, such a- -hooting pains, are rare, bnt may 
occur. There is no tendency to trophic joint-affection as in tabes. 
The sphincters are normal. 

Muscular power, although normal at first, diminishes as the dis- 
progresses. There i- atrophy of muscle. Spinal curvatures, 
talipes equinus, and equinovarus result The loss of muscular 
power i- sometimes limited to the lower extremities. 

'Hi.- mental <•* «iolit i< >n is generally affected. The children are 
slow at school. Imbecility ha- been recorded (Gowi 

Course. — Once inaugurated, the disease is progressive, bnt 
it may remain stationary at any Btage for some years. The dura- 
tion i- extended over year-. Growers gives the period as ten to 
twelve year-. The patients finally become bedridden, and, a- ;i 
rule, die from intercurrent disease. The anatomical changes have not 
afl yet been completely classified. This 18 dllc to the fact that in 

certain form- of hereditary ataxia resembling Friedreich's disease, 



520 DISEASES OF THE NERVOUS SYSTEM. 

Marie and Hoffmann have described changes other than those found 
in typical cases of that affection. The changes in Friedreich's dis- 
ease consist in a diminution in the transverse diameter of the cord 
and a sclerosis of the posterior and lateral columns, involving the 
pyramidal tracts. The neuroglia and vessels of the tracts are in- 
volved ; whether this is due to an arrest of development of a con- 
genital nature has not been determined. 

Differential Diagnosis. — The disease should be differentiated 
from true tabes. In the latter, there are the Argyll-Robertson pupil 
and optic neuritis, the visceral crises and shooting pains, but neither 
head-nodding nor nystagmus. The lack of intelligence and the 
family history are characteristic of Friedreich's disease. 

Prognosis and Treatment. — There is no cure for the affection. 
The treatment is designed to relieve the symptoms. 



ACUTE ATROPHIC PARALYSIS. 

(Acute Anterior Poliomyelitis ; Infantile Paralysis; Essential Paraylsis of Children.) 

This is the most common form of paralysis in infants and chil- 
dren. It is a disease characterized by loss of voluntary power, 
taking place within a few hours or days. Some of the paralyzed 
muscles recover ; others undergo atrophy. 

Occurrence. — There is doubt as to whether the disease occurs in 
foetal life. Duchenne has reported a case at the twelfth day. Such 
early cases are apt to be cases of hemorrhage rather than of polio- 
myelitis. The majority of cases occurring during the first year de- 
velop after the sixth month, and three-fifths of the cases before the 
tenth year are found to occur during the first three years. It affects 
the sexes equally. 

The etiology of the disease is still uncertain. Cases occasionally 
occur after exposure to cold, and after a traumatism or a psychical 
disturbance, such as fright. The relationship between these predis- 
posing elements and the disease is probably no more intimate than is 
the case in other affections. 

This disease is very frequent in the period of dentition, but 
since dentition has been regarded as a predisposing cause in most 
diseases, no close relationship is evident. It has been shown 
by Medin, Strumpel, and Zuppert that many of the cases of 
poliomyelitis occur after or during the course of the infectious 
diseases, especially measles, scarlet fever, and typhoid fever. It 
is probable that some toxin acting through the blood and blood- 
vessels causes the degeneration in the cord characteristic of the dis- 
ease. It is also probable that the epidemic occurrence of the affec- 
tion is due to its infectious nature. Medin, Pasteur, Sinkler, 
Putnam, Chapin, and Zuppert have reported epidemics. 



ACUTE ATROPHIC PARALYSIS. 521 

Symptoms. — There are four distinct periods in the development 
of the symptomatology : The period of onset, in which the symp- 
toms resemble those of an infectious disease ; the period of 
paralysis ; the period of retrogression, in which some of the para- 
lyzed parts recover while others remain permanently paralyzed ; 
and finally, the chronic state, in which there are permanent paralysis 
and atrophy. 

The Onset. — This is always acute. In most cases there are fever, 
vomiting, and diarrhoea. The fever may be slight (100 °F., 
37.7° CM or may mount to 104° F. (40° C). 

Complete paralysis sets in after these symptoms have continued 
for a few hours or days. In other cases the paralysis first attracts 
attention, and is followed by fever and constitutional disturbances 
persisting for days. General convulsions may usher in the disease, 
and be followed by coma lasting for days. At the termination of 
the coma, the patient is found to be paralyzed. The onset some- 
times resembles that of cerebrospinal meningitis. There are head- 
ache, vomiting, fever, and rigidity, the paralysis becoming apparent 
after the subsidence of these symptoms. Other cases have abso- 
lutely no premonitary symptoms. The patient goes to bed in 
health, but in the morning is found to be paralyzed. Patients 
sometimes suddenly fall, and on being raised up are found to be 
paralyzed. These are probably cases of acute spinal hemorrhage. 
In older children pain in the course of the nerves may usher in the 
paralysis. Pains in the joints and back may succeed the paralysis. 
Such cases closely resemble those of peripheral neuritis. 

The Paralysis. — The paralysis consists of a loss of power, which 
i- complete in two or three limbs or in parts of extremities. Seelig- 
muller found the relative frequency of involvement to be as follows : 
the right lower extremity, the left lower extremity, the right upper 
extremity, and the left upper extremity, in the order named. All four 
limbs may be involved, or only a hand and a leg. If all four limb- 
are at first involved, then- is weakness of the back. The patient 
cannot sit upright or hold the head erect. The cranial nerves 
escape, except in very rare cases, in which degeneration or inflam- 
mation involve- the medulla and its nuclei. There may be symp- 
toms which simulate those of bulbar paralysis. 

Different sets of muscles may be involved. Alter the first onset 
of the paralysis, some of the muscles may recover. Thus a child who 
ha- been unable to -it up or move the arms will recover the power 
to do so. Iii such cases one leg only may remain permanently 
paralyzed. 

Paralysis may develop -lowly in the course of one or two week-. 
After that time it come- to a standstill. In a period of from one to 
three month- either recovery will take place or the paralysis will 
be complete with accompanying atrophy. 



522 DISEASES OF THE NERVOUS SYSTEM. 

Atrophy in the paralyzed muscle is very characteristic of the dis- 
ease. It may be seen as early as the first week. Accompanying 
it, and appearing from the fifth to the seventh day, is the reaction 
of degeneration in the paralyzed muscle and nerve. The faradic 
and galvanic irritability of nerve and muscle are increased for the 
first two days. They then rapidly diminish, the former disappearing 
completely. The galvanic irritability remains increased for from two 
to six months ; it then diminishes, and if the paralysis is permanent, 
disappears at the end of one or two years. In rare cases all elec- 
trical irritability disappears from the onset. In others the faradic 
irritability in certain fibres and muscles returns after from six to 
twelve months. These muscles may partially recover, but remain 
atrophied and weak. There is usually no loss of sensation, but if 
it does occur, there is incontinence of urine. Reflex at the patellar 
tendon is lost and myotonic irritability is either lost or diminished. 
In cervical disease of the cord, or when only the posterior tibial mus- 
cle, or the muscles of the feet are paralyzed, the tendon reflex at the 
knee is present. In rare cases, the inflammation may spread from 
the anterior horns to the lateral columns. The lower extremities 
may then be paralyzed but not atrophied, and clonus may be present. 

Growth of bone is retarded, and one foot may after a time become 
shorter than the other. The joints become the seat of subluxations 
through the laxity of the muscle and lack of support. The articular 
ends of tho bones are not held in apposition. Through the shorten- 
ing of some muscles and the traction of others there will result 
various forms of talipes. The muscles in front of the tibia are 
affected more than those of the calf. The extensors of the thigh are 
more frequently paralyzed than the flexors. 

The muscles of the whole arm may be paralyzed, or, as in Erb's 
paralysis, only those of the deltoid group. The serratus, the pecto- 
ralis, the muscles of the back and neck, and the diaphragm may 
all be affected. 

Course. — The mildest cases rarely make a complete recovery. 
Death is very uncommon and occurs only in the early stages. It 
may supervene within two weeks from general paralysis or cerebral 
disturbance. Relapses are rare, second attacks unknown. 

Sequelae. — A cord which has once been the seat of this disease 
is naturally susceptible. Gowers states that he has seen chronic 
disease of the cord supervene later in life. Progressive muscular 
atrophy or lateral sclerosis may at some later time appear in the cord. 

The prognosis of acute atrophic paralysis is good as to life. As 
to the outcome of the paralysis, a prediction can be made only when 
all the muscles which show faradic irritability have recovered. Some 
children who in the second stage have shown complete paresis or 
paralysis from the cervical region down, gradually regain power 
in all of the affected muscles, only one limb or part of a limb being 



ACUTE ATROPHIC PARALYSIS. 523 

permanently affected. As a rule those parts, which after a week 
respond to faradism, will recover. 

Diagnosis. — At the onset, the case should he distinguished from 
one of the infectious diseases. Since the mode of onset is much the 
same, it is best, as in those diseases, to defer making the diagnosis until 
the initial symptoms have passed and the paralysis appears. When 
the paralysis is fully developed, it should be differentiated from forms 
o\' cerebral palsy. This in the majority of cases is difficult. The 
characteristic atrophy, the complete paralysis, the loss of knee- 
jerk, and the absence of contractures will all be of service. Those 
cases in which pain in the course of the nerves is present at the 
onset, should be distinguished from eases of multiple peripheral 
neuritis. Time and study of the cases will make this possible. In 
those forms of poliomyelitis in young infants, in which the muscles 
of the deltoid group are affected, Erb's traumatic form of shoulder 
paralysis should be excluded. Some cases closely resemble this 
form of paralysis. If the paralysis occurs immediately after birth 
and follows traction on the arms, poliomyelitis may be excluded. 
If the paralysis occurs after the sixth month, the diagnosis, in the 
absence of any traumatic history, should be that of poliomyelitis. 

Morbid Anatomy. — The theory of Charcot, that anterior polio- 
myelitis is a primary degeneration of the ganglion-cells in the 
anterior horns of the gray matter in the cord, has given way to the 
belief that there is severe inflammation superinduced by some toxic 
agent circulating in the blood. The change begins in a degenera- 
tion of the bloodvessels of the anterior median fissure. There is 
proliferation of the endothelial lining of these vessels. The in- 
flammatory process extends to the surrounding neuroglia and 
the ganglion-cells supplied by those vessels in the anterior horns of 
gray matter. In severe cases, the motor nuclei of the medulla may 
be involved. There may be inflammatory exudation and hemor- 
rhage. In recent eases, the ganglion-cells show granular swelling, 
vacuole formation, hyaline changes, disintegration, and atrophy. 
After month-, there is paucity of ganglion-cells in the region corre- 
sponding to the paralyzed members. They are seen in a few groups 
in the anterior horns or may be entirely wanting. Outside of the 
affected area, there may be a diminution of the number of ganglion- 
cells throughout the whole cord. The nerve-fibres corresponding to 
the ganglion-cells winch have disappeared are also wanting. There 
may be no marked change in the glia tissue, in the transverse; section 
of the anterior horn-, and in the general configuration of the trans- 
feree section of the cord. Alter a time, however, there will be 
sclerosis and atrophy of the affected horn. The sclerosis may affect 
the white columns. The anterior horn- and corresponding white 
substance may be transformed into a glia tissue resembling gelatin, 
the spaces containing fluid granules and disintegrated nerve-tissue 



524 DISEASES OF THE NERVOUS SYSTEM. 

(Ziegler). All these changes point to permanent injury to the spino- 
muscular neuron, the ganglion-cell of the anterior horn, and its 
nerve-fibre. 

The treatment of anterior poliomyelitis is symptomatic. In 
the stage of onset, perfect rest and quiet are indicated, and a few 
remedies to meet the symptoms. The bowels are kept open with 
calomel. Bromides are used if the patient is restless. Ice applied 
to the nape of the neck or to the head, as in cerebral disease, is 
useful if there are cerebral symptoms, such as headaches. Ergot 
has been given to act on the blood-supply of the cord, but is 
of doubtful value. After paralysis is established and atrophy has 
made its appearance, massage of the affected muscles, and electricity, 
especially of the galvanic form, are indicated. Later, in the chronic 
stage, much can be done for the sufferers by orthopedic appliances, 
such as braces and splints. If there is contraction of opposing 
muscles, tenotomy should be resorted to. In cases in which the 
joints have become the seat of luxation, arthrodesis has been prac- 
tised by surgeons with good results in increasing the power of the 
affected limbs. 



THE JUVENILE FORM OF PROGRESSIVE MUSCULAR 
ATROPHY (ERB'S TYPE). 

This disease is characterized by a weakness and progressive 
wasting of certain muscles. It begins in childhood or early youth, 
and involves, as a rule, the shoulder-girdle, the upper arm and pelvic 
girdle, and the thigh and back. The muscles of the forearm and leg 
remain for a time intact. This atrophy may be associated with true 
hypertrophy or pseudohypertrophy of some muscle. The pectoralis, 
the trapezii, the latissimi dorsi, the serrati, the rhomboids, the 
upper arm muscles and supraspinators, are apt to be wasted. The 
deltoids, supraspinal, and infraspinati may be normal or hyper- 
trophied for a time. There are no fibrillar contractions, no dis- 
turbances of sensation, and no reactions of degeneration and visceral 
disturbances. 



THE LANDOUZY OR DEJERINE TYPE OF THE FACIO- 
SCAPULO HUMERAL FORM OF MUSCULAR ATROPHY. 

This form in no way differs clinically or pathologically from the 
juvenile form of muscular atrophy. Authors include in this class 
all cases in which the atrophy begins in early life, as a rule, in the 
muscles of the face. The patients have a peculiar expression — 
so-called " facies myopathique." The lips are thickened (" bouche 



PSEUDOHYPERTROPHIC MUSCULAR PARALYSIS. 525 

de tapir " or tapir mouth). The shoulders later become atrophied. 
The supraspinal!, infraspinati, and the flexors of the hands and fin- 
gers remain normal, as do the muscles of deglutition, mastication, res- 
piration, and the laryngeal and ocular muscles. There are no fibril- 
lary twitchings. The spinal forms of progressive muscular atrophy 
differ from primary dystrophy in that the onset of the latter affec- 
tion is in the upper extremities. The disease is not hereditary, aud 
fibrillary twitchings and electrical reactions of degeneration are 
absent. 

Both these forms are probably clinical varieties of the pseudo- 
hypertrophic form of paralysis. 



PSEUDOHYPERTROPHIC MUSCULAR PARALYSIS. 

This disease is characterized by a progressive change in the size 
of many of the muscles of the body and by a diminution of their 
power. It was described by Duchenne in 1861. Since then the most 
notable work on the subject has been done by Gowers, of England, 
and Sachs, of this country. The male sex is more frequently af- 
fected than the female. From two to eight members of the same 
family are often affected. Isolated cases are uncommon. The dis- 
ease frequently affects the members of one sex in a family group. 
It is congenital but not hereditary. The antecedent cases, if there 
arc such, can usually be traced on the mother's side of the family. 
The mother may be herself unaffected. Intemperance does not seem 
to exert any influence on the occurrence. Gowers notes that frequent 
marriage of parties closely related tends to predispose to the develop- 
ment of the disease in the children. In one-third of the cases the 
disease appears when the child begins to walk, and in children who 
are late in learning. It may manifest itself in the mid-period of 
childhood. In another third of the cases the children are in ap- 
parently good health until the fourth or sixth year. Three-fourths 
of the cases -how symptoms of the disease; before the tenth year. 
The disease may not manifest itself until after puberty, and may 
only be noticed during convalescence from some intercurrent acute 
disease. 

The symptoms are impairment of power and change in the form 
of group- of muscles or of -ingle muscles. The impairment of 
power i< at first not very apparent. The muscles of the calves 
enlarge, and -how a very characteristic and significant hypertrophy. 
Mothers are :it first pleased with what appears to be muscular 
development of the children (Gowers). It is then noticed that 
although the muscles of the calves and glutei are large, the children 
are easily fatigued in mounting stairs. They i'all easily and rise 



526 DISEASES OF THE NERVOUS SYSTEM. 

with difficulty. This loss of power is at first interpreted as weak- 
ness, but when it is found to be progressive the children are brought 
to the physician. The gait becomes pronouncedly oscillating. The 
body is inclined so that the centre of gravity is brought successively 
over each foot. In trying to rise from the ground the patient places 
a hand on each knee in a very characteristic fashion. By grasping the 
thighs and throwing back the weight of the trunk, the patient helps 
himself into the erect posture. The weakness of the muscles finally 
becomes extreme. The patients can neither stand, walk, nor sit 
upright. They become bedridden. In the early stage, the muscles 
of the trunk may be normal, small, or atrophied, and those of the 
lower extremities much enlarged. Single muscles or groups of 
muscles of the arm and forearm may be enlarged (Plate XXII.). 
Finally, as the atrophy and weakness increase, there are contractures 
and distortions of the extremities and trunk. Equinus, lordosis, and 
lateral curvature are very marked. The knee may become fixed and 
distorted by contractures. The muscles most frequently affected in 
the beginning are those of the calves of the legs. These sometimes 
attain an enormous size. Those of the anterior part of the leg are 
not so much enlarged. The flexors of the knee commonly escape. 
The glutei and lumbar muscles are enlarged. The infraspinatus 
muscle is frequently enlarged, and stands out prominently ; it is often 
mistaken for the lower edge of the scapula. The deltoid is often 
large ; the serratus and the pectoralis are rarely affected. The triceps 
and biceps are frequently large, but often only in parts. The muscles 
of the forearm suffer only in a minority of cases. The intrinsic 
muscles of the hand are never affected. In that respect the disease 
is sharply distinguished from atrophies of spinal origin. The muscles 
of the neck are, with the exception of the clavicular portion of the 
stern omastoid, rarely affected. All the muscles affected are weak- 
ened, the smaller and atrophied muscles more so than the others. 
There is reason to believe that many muscles not visible are much 
affected. 

Electrical Reaction. — This is altered when weakness sets in. The 
electrical contractility to galvanic and faradic stimulus finally dis- 
appears. 

Reflexes. — The knee-jerk is at first normal. It later diminishes 
and finally disappears. It is never increased in a pure case. In one 
case in my hospital service there were increased reflex at the knee 
and foot-clonus. This case gave a history of a blow across the back. 
Sachs, with whom I saw the case, suspected a complicating myelitis 
of the cord. 

Sensation is unaffected and the sphincters remain normal. 

The course of the affection is prolonged and tedious. The 
disease is progressive. It may be ten or fourteen years before the 
patients succumb. They die of some intercurrent disease. If the 



PLATE XXII 




Pseudohypertrophic Paralysis in a Boy Eight Years of Age. 
Hypertrophy of the infraspinati well shown; also atrophy of 
the muscles of the thorax and hypertrophy of the glutei and 
the muscles of the lower extremity. 



DEFORMITIES OF THE SKULL AND SPINAL CANAL. 527 

disease appears after puberty, the course is slower than in cases in 
which the first symptoms are noted in early childhood. 

Varieties. — There are cases in which only one muscle or group 
of muscles of the extremities is enlarged, the others being small or 
normal in size. There are other cases in which all the muscles are 
small and waste progressively. 

Complications. — Chorea, poliomyelitis, myelitis, mental deficien- 
cies, and epilepsy may complicate the affection. 

Morbid Anatomy. — The gray matter of the cord and the nerves 
are normal in appearance. There may be slight hemorrhages. The 
neuroglia-cells have sometimes been found to be increased. The 
disease is, however, primarily one of the muscle-tissue. The muscles 
are pale-yellow. They are replaced mainly by fat and connective 
tissue. The muscle-fibre is narrower than is normal, although in 
advanced cases the residual muscle-fibre may retain its transverse 
stria tion. Where the muscle-fibre is narrow it becomes granular 
or is the seat of fatty or waxy degeneration and vacuolization. 
Empty sarcolem ma-sheaths are seen. 

The diagnosis is made from the progressive weakness, the gait, 
and the mode of rising from the recumbent position. The peculiar 
enlargement of the muscles of the calf and infraspinatus, the atrophy 
of the latissimus dorsi and lower part of the pectoralis, and the 
immunity of the intrinsic muscles of the hand are characteristic. In 
the stage of contracture, this disease differs from congenital spastic 
paraplegia in that there is no increase of deep reflexes. 

The prognosis in children is grave. The alfection is pro- 
gressive. 

Treatment. — Much can be done for the patients by means of 
massage and electricity. In the stage of contractures, while there 
is -till power, relief can be secured by tenotomy. 



DEFORMITIES OF THE SKULL AND SPINAL CANAL. 

These deformities do not strictly belong to the diseases of infancy 
and childhood. Only the forms most commonly met are here con- 
sidered. 

The faulty closure of the spinal canal causes a deformity called 
rachischisis or spina bifida. If the defect involves the spinal canal 
in its whole extent, there i- rachischisis totalis. The vertebrae form 
a shallow canal in which lies the rudimentary spinal cord covered 
with a thin membrane. If the defect of the bony canal is only 
partial, there being a sac-like protrusion of the cord and its mem- 
brane, there i- -aid to be a rachischisis cystica or spina bifida cystica 
or rachicele. 

Faulty development of the cranial bones with rudimentary brain 



528 



DISEASES OE THE NERVOUS SYSTEM. 



is called cranioschisis (Fig. 147). If with the cranial defects there 
are defects of the bony vertebral canal, there is said to be cranio- 
rachischisis. 

If there are only partial defects in the cranial bones, with saccu- 
lated protrusion of the membranes of the brain (pia and arachnoid), 
with fluid in the sac, there is a meningocele. Meningo-encephalocele 




Cranioschisis. Deficiency of the frontal, parietal, and most of the occipital hones. Pro- 
trusion of the cranial contents in shape of a sac covered by hair and scalp, and containing 
fluid and brain substance. Blindness ; idiocy. 

is a sac containing in addition the brain-substance. Encephalocele 
is a hernia of the brain and pia, no fluid being present in the sac. 



Spina Bifida. 

Spina bifida or hydrorrhachis is a congenital deficiency in the ver- 
tebral lamina?, through which the cord and its membranes protrude 
in the form of a sac containing fluid. The deformity is most fre- 
quently seen in the dorsolumbar, dorsosacral, and cervical portions 
of the vertebral canal. It rarely occurs in the middorsal region. It 
is generally single. It may occur both in the neck and in the 
lumbar region. 

The tumor may be small and only indicated by a fissure, or may, 
as in Broca's case, attain a circumference of 62 cm. It maybe flat 
or pedunculated. The latter form is uncommon. The surface of 
the tumor may be smooth or lobulated and uneven. The lobulated 
forms indicate divisions in the interior of the sac. The skin covering 



SPINA BIFIDA. 529 

the sac may be very thin or glistening. It may burst during delivery, 

may be thick and vascular, or covered with cicatrices and granu- 
lating ulcers. In some tumors the subcutaneous tissue can be made 
out ; in others the skin is atrophic. In rare cases the tumor is com- 
posed of a mass of mucous tissue situated between the skin and 
dura mater. In the interior of this mass there is a small cavity 
(Kirmisson). Von Recklinghausen and Muscatello have demon- 
strated that the statement that the sac of the spina bifida is lined with 
dura mater is incorrect. Hildebrandt has, however, found eases in 
which the dura lined the sac. The pia and arachnoid line the sac. 
The fluid in the sac is serous and colorless or lemon-colored. It is 
alkaline in reaction, rich in salts, and contains sugar. If inflam- 
mation is present, blood is found in the sae. The fluid is either 
outside the cord or in the central canal (Yirchow). 

Spina bifida is, with reference to the nature of the contents of the 
sac, divided into three forms : 

(a) Myelomeningocele, in which the fluid in the sac is situated 
between the cord and its membranes. 

(6) Meningocele spinalis, in which the inner surface of the sac 
is formed by the arachnoid and pia mater. 

(c) Myelocystocele, in which the fluid is situated in the central 
canal of the cord. 

The myelomeningocele forms a broad but not very prominent 
tumor, which may be found in the lumbosacral, cervical, thoracic, or 
sacral regions. At its base the tumor is reddish, and is covered 
with fine, long hairs. This zone is from 1 to 1J cm. broad. In 
the centre of the tumor there is a reddish-brown velvety vascular 
ana, the remains of the medullary vascular zone. The sac is formed 
<»f arachnoid and pia mater. Its interior is crossed by nerve-trunks. 
The cord is drawn outward and some nerves may arise from the pro- 
longations of the cord. Accordingly, there is an accumulation of 
fluid in the meninges (hydromeningocele), with an accompanying 
hernia of the cord (myelocele). 

Meningocele spinalis is the rarest form of spina bifida. The sac 

•mposed of pia and arachnoid. The latter may be much thick- 
ened. The opening into the vertebral canal if large may allow hernia 
of the cord. If the tumor is situated in the sacral region, the interior 
of the sac may contain the nerve- of cauda equina. 

Myelocystocele, hydromyelocele, or syringomyelocele, is that form 
of spina bifida in which there is a dilatation of the central canal of 
the cord. The dura is lacking in the sac, which is lined with cylin- 
drical epithelium. The spinal cord in part of its extent may be 
found in the sac, or may be found on the exterior wall of the sac 
and end there. It may break up into several bundles. In the 
interior the spinal nerve- form ;i series of loops with their convexi- 
ties posteriorly. They may return into the vertebral canal or may 



530 



DISEASES OF THE NERVOUS SYSTEM. 



end in the sac. Spina bifida is a primary agenesis. The growth of 
the sac is due to inflammatory processes. 

Symptoms. — The tumor is the chief physical sign. It is situated 
in the median line or may be at one side. It is round or elliptical 
and covered with thinned or thickened skin (Figs. 148 and 149). 
In the centre of the myelocystocele is a depression which gives the 
tumor a tomato-like appearance. The tumor may be soft, hard, or 
fluctuating. The defective vertebral laminae maybe discerned on 
palpation. The tumor enlarges and becomes tense when the patient 
assumes the upright posture, cries, or exerts himself. When the 



Fig. 148. 



Fig. 149. 





Spherical form of spina bifida lumbalis. 



Elliptical form of spina bifida, with fistulous 
opening (o) into the vertebral canal. 



patient takes the recumbent posture it becomes smaller. It also does 
so at each inspiration. 

In some cases the functions of the individual are normal. In 
others, the mobility and sensibility of the lower extremities are 
affected. Deformities of the foot similar to those seen in infantile 
paralysis are sometimes present. There may be incontinence of 
urine and feces. There are sometimes trophic disturbances, such as 
perforating ulcers. These are of value in the diagnosis of lumbar 
tumors which are apparently lipomatous in their nature and are 
covered with hair (Kirmisson). In such tumors, disturbances of 
sensibility occurring with perforating ulcers and deformity and 
atrophy of a lower extremity are significant of spina bifida. 

Course. — Spina bifida if left to itself may grow to a large size, 
may burst or ulcerate, and cause death by pyogenic infection of the 



SPISA BIFIDA. 



531 



meninges and cord tissue. In other cases a lineal nicer discharges 
fluid and closes up several times in succession. In some cases of 
spina bifida the tumors remain stationary in size until late in adult 
lite. In rare cases spontaneous cure results by inflammation of the 
pedicle of a pedunculated spina bifida. 

The diagnosis of spina bifida is not difficult if what has been 
detailed of the anatomy and symptomatology is borne in mind. 
Museatello gives the following characteristics of the various forms : 



Fig. 150. 



Fig. 151. 





Spina bifida lumbalis, with pes valgus on 
the right side ; also congenital subluxation 
of the hip. 



Spina bifida occulta pes ealcaneovalgus 
on the ritrlit side; pes equinovarus on the 
left side. 1 



In myelocystocele there is a round tumor with a wide base. The 
tumor is lumbosacral, elastic, translucent, and fluctuating, and does 
not diminish on pressure. Pressure causes tenseness of the fonta- 
nels. There may be scoliosis, Lordosis, abdominovesical fissure, 
and deformity of the foot. 

In myelomeningocele there i- ;i flat, soft, elastic tumor, either 
lumbar, sacral, cervical, or thoracic It may be complicated by 



FlgS. 1 1"— 1 •">! are from Kirmi— <>n. 



532 DISEASES OF THE NERVOUS SYSTEM. 

umbilical hernia, paralysis of the extremities and bladder, and de- 
formity of the foot. 

In meningocele there is a sacral pedunculated translucent tumor, 
but no disturbances of mobility or sensibility. 

Of considerable interest is the form called spina bifida occulta 
(Figs. 150 and 151). In these cases there may be no tumor, the 
seat of the deformity being indicated by a depression or dimple. In 
other cases, as in that shown in the illustration from Kirmisson, 
there is a smali tumor of doughy consistency on one of the gluteal 
folds. The tumor may present an umbilication. Spina bifida occulta 
should be suspected in cases in which abnormal sacral depressions or 
tumors occur in connection with clubfoot deformities or congenital 
incontinence of urine or feces, or of both. 

The treatment of spina bifida belongs to the domain of surgery. 
The treatment by injections of Morton's fluid (2 per cent, of iodine, 
6 per cent, of potassium iodide in glycerin) has been abandoned in 
favor of excision of the sac. 

Leading Authorities Referred to in Chapter VIII. 

Boltze, Otto : Zur operativen Behandl. des Hydroceph. Chr., Thesis, Halle, 1893. 

Crozer Griffith, J. P.: "Tetany in America," American Journal Medical 
Sciences, 1895. 

Griffith: Hereditary Ataxia, Amer. Jour. Medical Sc, 1889. 

Epstein, A. : "Kataleptische Erscheinungen," Prag. med. Wochen., 1896. 

Escherich, T. : "Tetanie im Kindesalter," Berlin, klin. Wochen., 1897. 

Fischl, B. : "Tetanie, Laryngospasmus u. Rachitis," Verhandl. d. Ges. f. 
Kinder., xiii. 

Bochsinger, C. : Myotome der Sanglinge Wien, 1900. 

Hirsch, Wm. : "Pathological Anatomy of Amaurotic Family Idiocy," Journal 
Nervous and Mental Disease, 1898. 

Ireland, Wm. W.: The Mental Affections of Children, Philadelphia, 1900. 

Kirmisson, E. : Lehrbuch Chirurg. Erkrank., Stuttgart, 1899.^ 

Macewen, Wm. : Pyogenic Infectious Diseases of Brain and Spinal Cord, 1893. 

McNutt, S. : " Apoplexia Neonatorum," Amer. Jour. Obstet., etc., 1885. 

Olser, Wm.: Chorea, Philadelphia, 1894. 

Pfaundler, M. : " Lumbalpunction," Beitrag zur klin. Med. u. Chir., Heft 20, 
1899. 

Botch, T. M. : " Khachischisis," Trans. Amer. Ped. Soc, 1900. 

Butimeyer : Virch. Arch., Bd. 90. 

Sachs, B. : Nervous Diseases of Children, New York, 1895. 

Sachs, B. : "Amaurotic Idiocy," Deutsch. med. Woch., 1898. 

Sdenger, A. : Neurasthenie u. Hysteric bei Kindern, Berlin, 1902. 

Thomson, J.: " Infantile Respiratory Spasm," Edinburgh Medical Journal, 
1892. 

"Congenital Stridor," British Medical Journal, 190C. 



CHAPTER IX. 

GENERAL DISEASES. 

RACHITIS. 

(Rickets.) 

Rachitis is a disease of nutrition causing well-marked changes 
in the structure and form of the growing bones. It is peculiar to 
infancy and childhood, and does not occur after the skeleton is 
formed. 

Etiology. — There are two forms of rachitis, the congenital or 
fetal and the post-natal. 

The occurrence of congenital, foetal, or intra-uterine rachitis is 
still a subject of much difference of opinion. According to some 
authorities (Kassowitz), 80 per cent, of the infants of the Vienna 
Maternity Hospital show evidences of rachitis. Epstein at one 
time demonstrated the great frequency of rachitic deformity at the 
oostochondra] junction of the ribs, in the infants of the Maternity 
Hospital in Prague. On the other hand, Monti, Guerin, and 
Virchow insist that fetal rachitis in the true sense is rare, and that 
an anomaly in the development of the primordial cartilage has been 
mistaken for rachitis, with which it has nothing in common. 

There are other forms of disease, such as achondroplasia, which 
have been described as fetal rachitis by Thompson, of Edinburgh, 
and Town-end, of Boston. These cases seem to be allied to cret- 
inism and arc classified by some authors as forms of it, but have 
nothing in common with that condition. 

Hemorrhagic rachitis is a term applied by some authors to Bar- 
low'.- disease or infantile scurvy. Rachitis is for the most part 
post-natal, and its onset occurs most frequently during the first year 
of life. It is rare after the third year. The sexes are equally subject 
to the disease. A moist climate favors it. It is very common in 
Germany and Austria, and is rarely met in Southern Asia or Central 
America. Fischl insists that it is peculiar to some races of people, 
and Snow, of Buffalo, has shown that Italians living in America, 
are peculiarly subject to it. It is most common among civilized 
Communities, in which infant-, especially those of large cities, are 
fed upon substitutes for breast milk. On the other hand, breast- 
fed infant- may develop rachitis, but in such cases investiga- 
tion of the milk by Pfeiflfer and others has not resulted in the dis- 



534 GENERAL DISEASES. 

covery of any peculiarity of the milk which might be looked upon 
as a causative factor. Rachitis develops in infants who have been 
weaned from the breast early and fed on artificial foods or sterilized 
milk. The early introduction of meats and solid food into the 
dietary of the infant has been cited as an etiological factor. 

That syphilis is a direct causative agent in rachitis (Parrot) can 
no longer be accepted. Heredity does not seem to exert any influ- 
ence. There are many theories as to the active and immediate 
causes. The principal theories are those which presuppose the lack 
of some element, such as phosphates or lime salts, in the food, and 
those that trace the processes of rachitis to a disturbance of nutritive 
functions caused by an increase of certain acids (lactic) in the 
stomach, a diminution of others (hydrochloric) and resulting intes- 
tinal functional irregularities (Monti, Zander). The intestinal dis- 
turbances cause the elimination of certain salts from food, hence the 
blood fails to receive what is necessary for the structure and forma- 
tion of the bones. 

Morbid Anatomy. — Rachitis is anatomically characterized by 
processes which cause an increased resorption of bone, deficient calci- 
fication of cartilage, and the formation of a characteristic tissue — a 
deficiently calcified bone, the so-called osteoid tissue (Ziegler, Kasso- 
witz, Schmorl). The increased resorption consists in an augmenta- 
tion of the number of areas of lacunar absorption. In marked 
rachitis the greater part of the bony skeleton is lost. The cortical 
area of the long and of the short bones becomes osteoporous. A 
large part of the lamellae of the cancellous bone is absorbed and dis- 
appears. In the flat bones the arrangement of outer and inner table 
separated by the intervening diploe is lost. The bone tissue is re- 
duced to a few lamellae. At the zones of periosteal and medullary 
ossification, the lamellae are replaced by osteoid tissue. This tissue 
is a new formation devoid of lime salts. 

The marrow of the osteoid tissue formed from the periosteum or 
medullary canal consists of a reticulum of striated connective tissue 
rich in bloodvessels and enclosing free round cells. Beneath the 
periosteum of the cranial and long bones there is formed, because of 
these changes, a spongy vascular tissue which is resistant to pressure 
and may be cut with a knife. While the rachitic process lasts, no 
lime salts appear in the lamellae of osteoid tissue, but as soon as the 
disease has spent itself those salts appear in the centre of the lamellae. 
Complete recovery results in calcification of these lamellae, which 
being proliferated leave the bone hardened and very much thickened. 
The pathological change in the endochondral ossification consists in 
an entire absence of a calcification zone. In severe rachitis, all 
signs of the deposit of lime salts are absent. There is a widening 
of the zone of proliferation of cartilage cells, and also of the columns 
of hypertrophoid cartilage cells. There is lastly an irregular forma- 



RACHITIS. 535 

tion of vascular marrow-spaces, which grow here and there into the 
cartilage from the hone. Thus at the junction of cartilage and hone, 
there is in the long hones no distinct line of ossification. The red 
marrow-spaces extend for varying distances into the cartilage. 

The abundant growth of bloodvessels extending from the peri- 
chondrium into the cartilage is accompanied by the substitution of 
osteoid tissue and marrow-spaces for the cartilage proper, as in 
periosteal and medullary ossifications. In rachitis the cartilage is 
never completely absorbed by osteoid tissue. Thus, on section, the 
bone shows, nearest the cartilage, the zone of proliferating cartilage- 
cells with hypertrophied cells in columns ; next to this is the zone 
of osteoid tissue in lamella? in which few T lime salts are deposited. 
Nearer the bone are lamella? of osteoid tissue, in the centre of which 
fully formed bone is deposited. The lamella? of osteoid tissue differ 
from those of normal bone in being much thicker and more abun- 
dant. The osteoid tissue is very resilient and easily bent, hence this 
property of rachitic bones. The process leaves the bones much 
thickened, especially at the epiphyseal extremities. The deformities 
of the chest, extremities, pelvis, and spine can thus be traced to 
the tendency of the rachitic bone to bend on pressure and traction. 
The effects of the process on the shape of the cranium and the 
delay in the formation of the teeth may thus be easily accounted for. 

Among other gross lesions connected with the clinical picture 
of rachitis is enlargement of the spleen. The organ may be very 
large and easily palpated below the border of the ribs. In such cases 
the liver may also be apparently enlarged. During life the enlarge- 
ment of the liver may be more apparent than real. The chest, if 
narrow and deformed, may cause downward displacement and rota- 
tion of that organ. In rachitic infants the lymph-nodes are more 
apparent on palpation than is normal. They, however, are never 
increa-od to the size attained in tuberculosis, syphilis, or eruptions 
of the skin, such as those of the exanthemata. The blood may show 
the changes of extreme simple anaemia — an increase in the nucleated 
red blood-cell- and other signs. 

Brain. — Slight or marked hydrocephalus is frequently found in 
rachitis. The relation between the two conditions is not clear. If 
the infant die- of an intercurrent disease, changes of a chronic 
catarrhal character may be found in the gut and signs of bronchitis 
or persistent bronchopneumonia in the lungs. These conditions follow 
the changes in nutrition which cause the rachitic processes elsewhere. 

Symptoms. — The most marked and general symptoms of 
rachitis are changes in the bony skeleton. 

The Head. — The shape of the rachitic head is very characteristic. 
The frontal bone bulges, giving the infant a very prominent fore- 
head. The parietal bones have a flare, caused by the formation of 
- ;it the centre- of ossification. The whole head has a euboidal 



536 GENERAL DISEASES. 

shape, which, with the proportionately small face, gives the character- 
istic appearance. The disturbances in bone formation cause the appear- 
ance of soft spots, especially in the vicinity of the lambdoidal suture. 
These (craniotabes) may be membranous in structure. They rarely 
appear on the frontal bones in the vicinity of the coronary suture. 
The spots of craniotabes appear in infants who develop rachitis before 
the sixth month (Monti), rarely after this period. They take four or 
five weeks to develop fully. In developed rachitis the occiput is flat 
and devoid of hair (Plate XXIIL). The anterior fontanelle, 1 which 
normally closes between the fifteenth and the eighteenth month, 
remains open for a long time, in some cases until the third or fourth 
year, or even to the sixth. The sutures are also slow in closing. The 
coronary sutures may remain open for two, and the longitudinal 
suture for three years. The lambdoidal suture does not in some cases 
close until the eighteenth month. 

If the thorax is affected by rachitis, the circumference of the head 
will exceed that of the chest. The lower jaw has an angular deformity, 
described by Fleischmann. This consists in a bending of the body 
of the jaw at the situation of the canine teeth. The body of the 
jaw is also rotated internally on its horizontal axis. If rachitis 
begins before the sixth month, dentition is delayed for periods 
varying up to a year and a half. I have a record of a case in which 
the first tooth appeared at the twenty-fourth month. If rachitis 
develops after appearance of the first teeth, the succeeding ones appear 
later than is normal. The structure of the teeth suffers. They 
show erosions, are easily broken, and become carious quickly. This 
is due to imperfect formation of enamel or dentine. Some time after 
their eruption, the incisors show a well-marked incurvation at the 
free border, which is due to erosion or breaking of the tooth. 

The thorax shows very characteristic deformities. Rachitis of 
the thorax in most cases develops in the second half year, and may 
continue into the third year. The first marked sign is the appear- 
ance of the so-called rib rosary. This is a thickening of the costo- 
chondral junction of the rib, in which the rachitic processes above 
described are very active. Deformity of the thorax follows in course 
of time. The thorax becomes prominent at the sternum and flat- 
tened in the midaxillary region from the axilla to the free border of 
tho ribs. There is a distinct incurvation of the thorax above, and a 
flaring below. The thorax is much narrowed at the clavicles, with 
a flaring outward of the lower ribs. Respiration, especially inspira- 
tion, is much interfered with. The sides of the thorax are drawn 

1 While the lateral and posterior fontanelles close during the first months of 
infancy, the anterior fontanelle increases in its longitudinal and transverse diameter 
with the growth of the cranium up to the twelfth month. The growth of the 
anterior fontanelle was first observed by Elsasser. Al hough denied by Kas- 
sowitz it has been recently proved by Rhode that the contention of Elsasser is 
correct. 



PLATE XXIII 




Rachitis. Showing the cuboidal shape ol the head, the 
thoracic deformity, the beaded ribs, the protuberant abdo- 
men, and the enlarged lower end of the radius. 



RACHITIS. 



537 



inward i 
severe b 
sides of 
sternum 
resulting 
ribs or 
progress, 
so when 



it the diaphragm at each inspiration. In an attack of 
ronchitis or bronchopneumonia, the drawing inward of the 
the chest becomes still more marked. In some cases the 
alone is affected. There is a sinking of the sternum, with 

chest deformity. Some forms of rachitis affect only the 
part of the thorax. While the rachitic process is in 

the chest circumference does not increase ; it begins to do 
the disease has run its course in the thorax. 




Rachitic deformity of the spine Uniform curvature backward. 

Pain. — When the infant is raised from the chair or crib, it 
eric-. This is the result of the painful nature of the rachitic process 
in the bone-. Forcible percussion of the chest will cause pain. On 
account of the deformity of the chest and the consequent interference 
with its physiological functions, the lung is prone to contract in- 
fections, such a- bronchitis and bronchopneumonia. Atelectasis is 
also a common complication. The clavicle becomes bent and frac- 
tures on the slightest traumatism. At the termination of the rachitic 



538 



GENERAL DISEASES. 



process, the clavicle and scapulae are much thickened. Virchow 
has shown that the scapula becomes the seat of an angular deformity. 
Spine. — On account of the relaxation of the ligaments of the bodies 
of the vertebrae and of the rachitic processes in the bodies of the 
bones themselves, there is in most rachitic infants a bending backward 
of the dorsolumbar spine (Fig. 152). The curvature is very marked 

Fig. 153. 




Angular deformity of the spine, due to Pott's disease, as distinguished from the deformity 

due to rachitis. 



when the infants are held in the arms. It differs from deformity 
due to Pott's disease in that it is not angular, and in that the 



RACHITIS. 



539 



spine can be straightened and even curved forward with ease (Fig. 
153). 

Lateral curvatures of the spine arc also found. If the spinal 
deformities occur early in infancy, they disappear as the rachitis heals 
and the ligaments and muscles regain a normal tonicity. On the other 
hand, should the rachitic process attack the spine late in the third or 
fourth year, the deformities are perpetuated. 'Phis is especially the 
case if the pelvis is also affected at that time (Monti). 

The pelvic deformities which result from rachitis are chiefly flat- 
tening of the pelvis, and the pseudo-osteomalachic pelvis. 

Upper Extremities. — The epiphyses are much swollen and, in rare 
cases, painful. The wrist is flat and much broadened. If the 

Fig. 154. 




6 jO Ltftny. 

Marked peneral rachitis in a child thirteen months of age. The phalanges of both hands 
thickened, simulating dactylitis syphilitica. Other osseous deformities present character- 
istic of rachitic. No syphillK. 



rachitis is elsewhere not marked, the physician should be careful not 
to mistake a normal enlargement in this situation for rachitis. In 
exceptional cases, the elbow and shoulder-joint show similar changes. 

On account of the traction of the flexors and pronators, the fore- 
arm may be incurvated and the bones twisted on their longitudinal 
axes. The resnll Is a more or less fixed position of pronation in the 
forearm. The arm i- rarely curved in this manner, but it may, like 



540 GENERAL DISEASES. 

the clavicle, be fractured after slight traumatism. As a result of 
rachitis and deformity, the growth of the bone in length is much 
interfered with. 

The phalanges are sometimes the seat of the rachitic processes. In 
one severe case I found all the phalanges thickened in the diaphyses. 
This case bore a very close resemblance to dactylitis syphilitica, 
especially as there was pain on pressure (Fig. 154). 

The deformities of the lower extremities are more marked than 
those of the upper ones. On account of the pain experienced, the 
infants refuse to stand ; they will draw the extremities up under- 
neath the abdomen, if any effort is made to make them do so. In 
other cases, when attempts are made to stand, the weight of the 
body and the muscular traction (Kassowitz) cause deformity. The 
femur, tibiae, and fibulae curve outward, giving the so-called " bow- 
leg " deformity (Plate XXIV.). This may in extreme cases result 
in a deformity of the heads of the bones entering into the forma- 
tion of the knee-joint. The ankle-joint may suffer a varus de- 
formity. The femur and tibiae may curve inward, and a knock- 
knee deformity result. In all cases, there is relaxation of the liga- 
mentous joint-structure. The tibia sometimes becomes much thick- 
ened and curves anteriorly, giving the so-called " sabre deformity." 
It may be twisted on its longitudinal axis. I have seen severe 
rachitis of the femur and tibia result in multiple fractures. 

The deformity at the hip-joint, which later in life follows changes 
in the angle made by the neck' of the bone with the shaft of the 
femur (coxa vara), is believed to be due (Whitman) to rachitis. The 
children are late in walking. The musculature is weakened through 
disuse. 

When the children assume the sitting posture, they cross the lower 
extremities in tailor fashion. In the majority of cases of rachitis, the 
abdomen is protuberant. As a result of the defective nutrition, 
the musculature of the gut is weakened in the same manner as 
that of the extremities. Tympanitic distention is the rule. 

Intestinal disturbances are common in rachitis, but are not a 
result of the process. Henoch shows that rachitis may be present 
with an apparently normally functionating intestine. 

The spleen is enlarged in many cases of rachitis, but retrogrades 
to the normal size after the disease has run its course. 

The blood shows the changes found in ordinary mild or severe 
simple anaemia. 

The liver may be slightly enlarged. 

Anaemia of the skin and mucous membranes is frequently found. 
It may be so extreme as to cause the skin to have a yellowish 
waxy hue. Rachitic children perspire freely at night, especially 
about the head. Unless the skin is kept scrupulously clean, 
sudamina, furuncles, and eczema of all kinds will result. 



PLATE XXIV. 




Rachitis Showing the deformity of the thorax, and 
marked bowing of the tibiae. 



RACHITIS. 541 

Nervous System. — There is no doubt that certain nervous affections, 
such as tetany, laryngismus stridulus, attacks of inspiratory apnoea, 
spasmus nutans, and the so-called barn-yard crowing or congenital 
stridor of the larynx (described by Thomson), occur most frequently 
in subjects of rachitis. Some authors (Kassowitz, Jacobi, Escherich) 
trace a distinct etiological connection between these conditions of 
instability of the nervous system and rachitis. 

Hydrocephalus occurs in rachitic subjects. In cases of severe 
rachitis, an appearance of mild hydrocephalus is given to the face 
by a downward depression of the eyeball. The sclera of the eyes 
is thus slightly exposed. The appearance seems to be caused by 
a depression of the orbital plates of the frontal bone by the over- 
lying frontal lobes of the cerebrum. In many cases of severe rachitis, 
the wide fontaneile, its tenseness, and the open coronal and temporal 
sutures give a picture like that of a non-progressive, mild hydro- 
cephalus which is simply a feature of the nutritive disturbances 
taking place in the brain as elsewhere. 

Severity of the Affection. — These symptoms are not present in 
all cases of rachitis. In some cases there are only very slight signs 
of the disease, such as a slightly cuboidal shape of the head or a 
scarcely appreciable bending of the ribs without any deformity. In 
such eases even an expert may be in doubt as to the presence of 
swelling of the epiphyses. In other cases an intercurrent affection, 
such as tetany, will cause the physician to seek for signs of rachi- 
tis, which may be so slight as to have previously escaped notice. 
( feaniotabes is sometimes absent in marked cases. Delayed denti- 
tion is not the rule. Rachitis may be very evident in cases in which 
the teeth appear in their normal order. 

Duration. — In such a disease as rachitis it is to be expected that 
the duration of the affection will vary greatly in different subjects; 
it may last month- in some cases, in others years. The first favorable 
sign i- the attempt of the infant or child to walk, but children with 
marked and progressive rachitis sometimes walk early. 

Increase in weight and in the chest circumference, an improve- 
ment in symptoms, such as anaemia and intestinal disturbances, and 
the cessation of pulmonary complications are indications that the 
disease baa come to a standstill. 

The diagnosis of rachitis before the development of the physical 
Bigns in the bones of the head, chesty and extremities is scarcely pos- 
sible Monti thinks that an increase of lactic acid in the stomach 
content- i-. if then- are intestinal disturbances, strong presumptive 
evidence of early rachitis, but the increase of lactic acid may be tem- 
porary, and the general practitioner will find it hard to estimate. 
Once the bone symptoms develop, there i- no difficulty. In cretinism, 
Mongolian idiocy, and syphilis, there are changes in the bones which 
very closely resemble those seen in simple rachitis. Yet in all these 



542 GENERAL DISEASES. 

conditions there are other signs which will make the diagnosis clear. 
In syphilis, rachitis is an accompanying condition. There is no 
etiological connection between the two affections. In every case of 
tetany, spasmus nutans, laryngismus, congenital stridor of the lar- 
ynx, inspiratory apnoea, or eclampsia, the physician should not fail 
to look for evidences of rachitis. The improvement in these con- 
ditions will often depend on the management of the rachitis. 

If the infant cannot stand, the limbs may exhibit a variety of 
pseudoparalysis. Paralysis may be excluded by making an electri- 
cal muscle test. Although infants Avith rachitis will not stand, 
they move the lower extremities vigorously when lying down. 
This is not the case in the palsies ; the faradic and galvanic muscle 
tests and the presence of the normal reflexes will fix the diagnosis. 
In severe cases of cranial rachitis, it is not always an easy task to 
exclude hydrocephalus. While marked hydrocephalus presents no 
difficulties, a slight hydrocephalus is not always apparent. In such 
cases the head circumference is measured once a month. An 
abnormal increase in the circumference, a wide tense fontanelle, 
and open sutures indicate hydrocephalus. 

Occurrence. — West has demonstrated that rachitis in the United 
States is not confined to negroes and immigrants. He has shown 
that its greatest frequency is among the natives of Eastern Ohio. 

The Blood. — Through a study of the blood in rachitis Morse has 
come to the conclusion that anaemia of any form may exist. It is 
generally an anaemia in which the number of red blood-cells is nor- 
mal or nearly so. The haemoglobin is reduced, and there is a con- 
sequent reduction in specific gravity. There is leucocytosis, especially 
in the cases with splenic enlargement. 

Rachitis tarda is a term applied by Kassowitz and Genser to 
those cases which, instead of running their course in two or at most 
three years, continue in the active stage for eight, ten, or even 
twelve years. Kassowitz and his pupils record cases of florid rachitis 
at the tenth and twelfth year. I have seen a case of florid rachitis 
in a female child eight years of age. She had all the signs of rachitis 
of the head, thorax, and arms. The lower extremities were perma- 
nently crossed in tailor fashion. The bones were painful, and those 
of the lower extremities were the seat of multiple fractures. The 
teeth were decayed. In Genser's case the milk teeth having de- 
cayed and fallen out, the permanent ones failed to appear. 

Prognosis. — If rachitis is not complicated by any intercurrent 
affection, the prognosis, even in the severe forms, is generally good 
so far as life is concerned. On the other hand, an intercurrent af- 
fection, such as pertussis or bronchopneumonia, is likely to run a 
severe course and prove fatal in a rachitic subject. If the rachitic 
process is complicated by nervous disorders, it is frequently fatal. 
Sudden death in eclampsia, tetany, or laryngismus is not uncommon. 



RACHITIS. 543 

The prognosis as to deformity will depend on the severity of 
the affection. Subsequent treatment will not always correct deformity 
of the pelvis and long hones. The conditions often remain perma- 
nent. Fortunately rachitis in this country is not among the native 
born of so severe a type as in Germany, Austria, and Switzerland. 
If marked hydrocephalus is a com pi i eating condition, the prognosis 
is had. 

The treatment of rachitis differs greatly in different countries, 
but there are certain fixed principles upon which all methods are 
based. Prophylaxis is an important element in all methods. An 
infant at the breast should not be weaned too soon if the breast milk 
is sufficient in quantity and the infant is increasing in weight. 
Weaning should not be attempted until the ninth month. If it is 
done in the fall or winter, the milk should be obtained as soon as 
possible after the time of milking. There is no need of sterilizing 
the milk if it has been collected with care. It is at most pasteurized. 
Cows' milk should be diluted so that the albuminoid elements may 
be reduced. Articles of diet rich in albumins, such as eggs, should 
not be given early, nor should the infant be permitted to eat 
meat in any form, potatoes or vegetables. The early use of these 
articles of diet favors the development of rachitis. When the breast 
milk is insufficient, it should be supplemented by the requisite 
number of artificial feedings. Rachitic infants do better on two 
breast-feedings a day with several artificial feedings, than on arti- 
ficial feeding alone. Cows' milk is the substitute for the breast. 
It should be properly prepared. Many severe forms of rachitis 
can be traced to the use of infant foods. 

Artificially fed infants should, after the sixth month, be allowed 
a limited amount of fresh fruit juice once a day. Orange juice is 
best, but cannot be borne by all infants. An infant should not be 
allowed to become inordinately constipated. In other words, treat- 
ment i- directed toward eliminating all predisposing factors to the 
development of the disease. Some breast-fed infants do not thrive. 
They develop serious disturbances of nutrition and colic, remain sta- 
tionary in weight, and have irregular and green curdy movements. 
In such cases, the infant should be weaned or given another wet- 
DUrse. Damp, ill-ventilated dwellings predispose to the develop- 
ment of rachitis. 

Bathing. — Young infants should not be bathed in water which is 
much below the temperature of the body. Such bathing prevents 
increase in weighl and causes disturbances of nutrition. The tem- 
perature of the bath should be practically the same throughout 
infancy. An infant cannot be hardened without disturbing the 
metabolism. The addition of sea salt to the bath water is advised 
by some physicians, and brine baths are in general use. There 



544 GENERAL DISEASES. 

are other kinds of baths which contain iron, but I have had no ex- 
perience with them. They are not used in America. 

Living at the sea-coast is believed to exert a very favorable in- 
fluence upon rachitic infants and children. On the other hand, if 
there are affections of the chest and lungs, such as bronchitis of a 
chronic variety, the humid atmosphere of the coast is not likely to 
be beneficial, and mountain resorts are better. 

Medicinal Treatment. — Cod-liver oil has long been a favorite drug 
in the treatment of rachitis. It should be given in the emulsion 
with the hypophosphites of lime and soda. An infant a year old 
should take half a teaspoonful three times daily. In intestinal dis- 
turbances, it should not be administered, for fear of aggravating the 
symptoms. The external application of the pure oil to the body can 
hardly be useful, since it certainly interferes with the metabolism of 
the skin. 

Iron in the form of the hypophosphate, grain j (0.06) 
given four times a day, or the saccharated carbonate, grain ij 
(0.12) three times daily, is of great utility. The pomate of iron 
or the more digestible peptonates of iron and manganese are much 
used. The combination of thyroid extract and iron has, in some 
cases of extreme anaemia with enlarged spleen, been of great utility. 
I have used this combination only in cases where there was extreme 
anaemia with rachitis : 

Thyroid ext gr. £ (0.03). 

Sacch. carb. iron gr. iij (0.2). 

Tabes pulv. t. i. d. 

Henoch has advocated the use of thyroids in the advanced cases 
of rachitis. His view is opposed by other authorities (Monti). I 
advise the cautious use of thyroids in combination with iron in 
selected ambulatory cases only. Hospital cases will not do well 
on this therapy. 

The lactophosphate of lime is advised by some authorities, but 
is of little value. 

Phosphorus. — It has been shown by Kassowitz and Wegner, 
and confirmed by Virchow, that in the lower animals phosphorus 
administered in sufficient dosage causes an increased activity in the 
processes at the epiphyseal ossification zone. The bone becomes 
more compact, but there is neither an increase of its diameter nor 
deformity. Kassowitz has contended that the same results are ob- 
tained in the human subject. On this question, there is wide differ- 
ence of opinion. Jacobi was among the first in this country to ad- 
minister phosphorus as a remedy for rachitis. He especially advises 
its use in cases of craniotabes. I have found that some children do 
well on it, while in others it causes gastric and intestinal disturbances. 
I have used the emulsion of lipanin, so much recommended by Kas- 



RHEUMATOID ARTHRITIS. 545 

sowitz, as a vehicle for the phosphorus. Enough of the phosphorus 
is put into the oil to make a teaspoonfb] of the emulsion equal to 
^4-^ grain (0.00024). Thompson's solution of phosphorus may also 
be used. Preparations of phosphorus, even those made with oil, 
deteriorate. Kassowitz advises the formula to be made up with 
recently dissolved phosphorus. 

There are those who, like Henoch, Monti, and Heubner, regard 
the phosphorus treatment of rachitis with distrust. The treatment 
of rachitis with glandular extracts is still a matter of empiricism. 
The treatment of the convulsions of laryngismus will be discussed 
in the section on that condition. 

Surgical Treatment. — It is not within the scope of this book to 
dilate on the surgical or orthopedic management of rachitic deformi- 
ties. It is, however, proper to state that it is neither right nor 
necessary to place every infant with marked spinal curvature due to 
rachitis in a plaster jacket. A young infant with marked backward 
curvature of the spine will gradually lose this deformity as its 
muscles improve in tonicity, but if placed in a plaster jacket will 
probably develop a subacute bronchitis or pneumonia. The lung is 
insufficiently inflated as it is, and becomes much more so if the soft 
thoracic walls and abdomen are encased in a plaster east. In such 

- the sitting posture should be avoided. The infants are kept 
in the arms or sleep on an ordinary hair mattress and hair pillow. 
It is not possible to keep them in any particular posture. Massage 
of the >pine is of questionable utility. 

Operations for the correction of deformities of the long bones 
should not be carried out until the rachitic process has come to a 
standstill. Surgeons sometimes advise the correction of deformities 
in young infant- by encasing the limbs in plaster while the bones 
art- -till soft. 

RHEUMATOID ARTHRITIS. 

Arthritis Deforma 

This affection should be sharply differentiated from all forms of 
chronic or subacute articular inflammation. Charcot and Weil have 
described tin- form of arthritis in children. The cases are not com- 
mon. Aft<-r th<- publication of my ease, two other- wen- described 
in the American literature, one of the descriptions being given by 
Mange-. Cases of arthritis deformans or rheumatoid arthritis in 
children are referred to by Osier (4 cases) and Henoch (5 cae 
The onset of the disease is either sudden after an exposure to 
eold and wet. or -low. In one form, after an onsel of chills and 
fever, soreness and pain in several joint- appear. The child is at 
first able to be about, but. a- the joint- become more and more 
affected, complete disability results. The pain in the joints be- 

35 



546 



GENERAL DISEASES. 



comes so marked as to interfere with sleep. After a few months 
fcHe patient may be unable to walk. In some cases the en- 
largements and pain begin in the lower extremities and gradually 
involve other joints. In others the onset is slow. The joints of 
the upper and lower extremities gradually become painful, and after 
repeated attacks remain swollen and limited as to motion. The ends of 
the bones are enlarged and there is effusion in some joints. With 
the progressive involvement of the joints there is atrophy of the 



Fig. 155. 




Arthritis deformans in a child seven years old. Deformity of all the joints with fixation. 
Child forced to assume this attitude awake and in sleep. 

muscles, as in the adult form of the disease. When the disease 
is fully developed the condition is pitiable. In my case almost 
every joint in the body, including those of the cervical vertebrae, 
was involved ; the tempo rom axillary articulation, the shoulder, the 
elbow, the small finger-joints, the hips, knees, ankles, and toes, 
were all affected. The patient slept in a semi-upright posture, 
and had to be carried from place to place. There was very 
limited and painful motion in all the affected joints (Fig. 155). In 



ACUTE ARTICULAR RHEUMATISM. 547 

some cases there have been exophthalmic goitre and tachycardia 
(Manges) j in others there also has been enlargement of the lymph- 
nodes, liver, and spleen. 

Brabazon found that of 100 cases of this affection, only 3 per 
cent, occurred between the ages of live and fifteen years. Two 
theories have been advanced to explain this joint-affection ; one, 
that of Charcot and Weil, is the neurotic theory, which is plausible 
because of the bilateral nature of the affection, the atrophy of the 
muscles around the joints, the changes in the skin which becomes in 
time tense and shining, and the enlargement of the ends of the 
bones which enter into the formation of the joints. The infections 
theory is supported by the fact that there is in many cases a diurnal 
fluctuation of temperature of a degree or a fraction of a degree above 
the normal. The lymph-nodes are enlarged ; the liver and spleen are 
also enlarged in some cases. The heart is not usually involved. 

The prognosis as to life is good. 

Treatment by massage, warm baths, and patient manipulation 
of the joints under anaesthesia, may effect slight improvement. In 
my case improvement was noted after a year of constant treatment. 
Iodide of potassium is the only drug which relieves the pain. In 
some cases it exerts a favorable influence upon the course of the 
disease. 

ACUTE ARTICULAR RHEUMATISM. 

(Polyarthritis Rheumatica ; Rheumatic Fever.) 

Although acute articular rheumatism is still regarded by some 
author- a- a constitutional disease caused by disturbances of nutri- 
tion which result in local manifestations, the general tendency is to 
regard it a- an acute infections disease. The infections agent, 
whether bacterial or toxic, attacks the serous cavities, such as those 
of the joint-, the pericardium and endocardium, and the pleura. 
The resemblance of rheumatism, especially in children, to the infec- 
tion- i- sufficiently great to warrant a serious consideration of this 
theory. Tim- in septic endocarditis in children, as in the adult, 
there are symptoms of pain in the joints. Chronic cases of 
endocarditis of a rheumatic nature in course of relapse occasionally 
take a septic course. Certain diseases, such as erythema nodosum 
and pelio-i- rheumatica, in which the joint-symptoms are marked, 
are regarded n- being caused by infection of a bacterial nature. I 
have lately seen such a case of peliosis. In other diseases, such as 
scarlet fever, measles, and varicella, there are joint-affections which 
are recognized to be of an infection- nature. Lastly, both American 
(Packard) and English writers have called attention to the well- 
observed clinical f;ict that there are form- of rheumatism and 
endocarditis which follow attacks of tonsillitis of the lacunar type 



[AS GENERAL DISEASES. 

or accompany them. It is true that the infectious agent, whether 
bacterial or toxic (Chvostek), is still to be discovered. Time may 
show that not one, but a variety of micro-organisms are capable of 
causing rheumatism of the acute articular type in a susceptible 
organism. Streptococci have been found in the exudate of the joints 
(Hlava). Staphylococci aureus, citreus, and alba have been found 
in the blood (Gutmann, Tizzoni, Bouchard). The pneumococci of 
Frankel and the Diplococcus tenuis have been found in the joints 
(Leyden). Singer has found similar micro-organisms in the urine. 

Heredity is among the predisposing causes. Children whose 
parents are markedly rheumatic, may suffer severely from the 
affection. Cold and exposure certainly predispose to the disease 
or precipitate attacks. The disease is prevalent in countries, such as 
England and America, in which climatic influences are favorable to 
its development, and is especially prevalent in the moist and cold 
seasons of the year. 

Age. — Rheumatism has been described as occurring in early 
infancy (Jacobi). I have published a case in an infant of nine 
months. Rauchfus, Chapin, and others have also described cases in 
infants. These cases were collected by Miller, who, with his own 
case (nine months), found in the literature only 19 authentic cases 
in nursing infants. Although rare in infancy, rheumatism is not 
uncommon in children from the fifth to the tenth year. The ma- 
jority of the cases of rheumatism occur between the tenth and the 
twentieth year. 

Sex. — Among adults, males are more subject to the disease. In 
children, however, although certain observers contend that it is more 
prevalent among girls, other statistics show that it has the same fre- 
quency of occurrence in the sexes. 

Symptoms. — Certain peculiarities, pointed out by Jacobi, seem to 
differentiate acute articular rheumatism of infants and children from 
the same affection in adults. Not many joints are attacked. The 
pain and swelling are generally not very marked. The redness of 
the joint is slight or altogether absent. The temperature is rarely 
high. The smaller joints, such as the maxilla, sternoclavicular articu- 
lation, and those of the vertebrae, are rarely attacked. The larger 
ones, such as the ankle-, knee-, and wrist-joints, are most commonly 
affected. 

Cardiac complication is the rule. As Jacobi has pointed 
out, endocarditis is sometimes the first manifestation of the dis- 
ease. 

Clinical Types. — In infants and young children the first signs are 
swelling and pain in the affected joints. The infant in the nursing 
period cries, has fever, and is restless. On investigation it is found 
that the patient favors one extremity, and shrieks with pain when it 
is touched. Children of two and one-half years or more refuse to 



ACUTE ARTICULAR RHEUMATISM. 549 

walk, and will complain of the affected joint, ankle, or knee. There 
will be fever and constitutional symptoms. The ankle, and in some 
cases the smaller joints of the foot are swollen. One of the knees, 
the wrist, and elbow may also be swollen, red, and painful. The 
fever rarely rises above 1*03° or 103.5° F. (3D. 4° C). In other eases 
there are fever and restlessness, and sometimes pains of an indefinite 
character in the joints. A history of pain may be elieited by care- 
ful questioning and examination. 

The physician may mid an angina, slight or marked; the heart 
may show signs of endocarditis of an acute type. There are pains 
in the joints but no true rheumatic swellings. The pains more 
closely resemble those in uncomplicated angina tonsillaris. In 
older children, with the endocarditis, a history of joint-pains may 
be obtained. In other eases, the pains in various joints are the only 
symptoms. There is no swelling or redness, and no endocarditis. 
Some eases have no fever. The classical eases, however, closely 
resemble those of the affection as seen in the adult. There may be 
premonitory symptoms, but as a rule the patient is brought to the 
physician with the enlargement of the joints fully developed. After 
the joints have become enlarged they may return to the normal in a 
few days, but may again be the seat of pain and swelling. The 
swelling in the joints of children does not persist as long as in the 
adult subject, and as a rule children are less disabled. In many 
- - there are gastric pains. The children do not show any greater 
tendency to perspire than adults. 

Endocarditis is usually a complication of rheumatism in children. 
It- absence is rare. Only 2 of 15 of my hospital eases during the past 
year were free from cardiac complication. The most common cardiac 
l<-i<>n i- found at the mitral valve and is manifested by a single 
systolic murmur at the apex. Three of the cases showed the pres- 
ence of a doable mitral murmur. Endocarditis sometimes does not 
reveal its presence by any symptoms, and is only discovered on a 
careful examination. In many of the cases there is also a pericardial 
friction first heard at the apex or base of the heart. The pericardial 
friction is more common in children than is generally supposed. 
The pericarditis frequently remains in the dry friction stage, and does 
not advance to effusion. Pleuritis and bronchopneumonia are among 
the Less common manifestations. The endocarditis sometimes occa- 
sions parn and distress. The presence of endocarditis a- an acute 
affection in first attack- of* rheumatism has been dilated upon in the 
section on Endocarditis. 

Chorea. — The relationship of chorea and rheumatism has been 

discussed. I have -ecu a child of two and one-half years born of 

a rheumatic mother, develop first rheumatism and endocarditis, and, 

within a few day-, marked chorea. On the other hand, in many 

a of chorea, there i- neither endocarditis nor a history of rheu- 



550 GENERAL DISEASES. 

mat ism in children or parents. The statistics of chorea in hospital 
service show a greater frequency (39 per cent.) of cardiac disease with 
or without a history of rheumatism than the ambulatory cases. This 
is explained by the fact that only the severer cases of chorea come 
to the hospital. 

The prognosis of acute articular rheumatism in infancy is good 
as to life. On the other hand, it is a disease which is likely to recur 
and to be complicated by endocarditis. The latter fact should cause 
the physician to reserve any definite prognosis until the course of 
the disease has been carefully studied. The prognosis of rheumatic 
endocarditis can never be definitely made. All depends on the 
amount of damage done to the valves and the frequency of the 
recurring attacks. 

The treatment of acute articular rheumatism in children is not 
essentially different from that followed in the adult. I use salicylic 
acid, bicarbonate of sodium, salicylate of sodium, and oil of winter- 
green. 

The bowels should be kept open with an alkaline cathartic. The 
Carlsbad salt or Rochelle salt given daily is best adapted for this 
purpose. The patient is put on a milk diet ; fruit juices are allowed. 
The patient is kept in bed. The affected joints, if painful, are either 
immobilized or wrapped in cotton. Some prefer to paint the joints 
with a solution of oil of wintergreen, and then wrap them in cotton. 
Salicylate of sodium is given internally in doses of grains ij to v 
(0.12 to 0.3) according to the age. Young children are given a dose 
every three hours. Older children are given doses of grains vij to x 
(0.5 to 0.6). The effect is watched. Salol or salophen may be 
given. The salicylates sometimes not only act as irritants to the 
stomach, but also have no appreciable effect on the course of the 
disease. In such I have given bicarbonate of sodium in increas- 
ing doses until the urine becomes alklaine. Endocarditis is treated 
on the principles laid down in the section on that disease. While 
under treatment the patient is given alkaline waters. During con- 
valescence the various preparations of iron are of great value. The 
preparations of lithium are useful in cases in which there are 
indefinite pains in the joints. The carbonate is given in doses of 
grain j (0.06) three times daily. It is given in capsule to older 
children after meals. The method of treating rheumatic subjects 
by the occasional administration of salol or salicylates for months 
has been suggested. The salicylates upset the stomach, so that the 
alkalies alone are available. The patient is given grains v (0.3) of 
sodium bicarbonate twice daily every other day. Vichy water is used 
regularly. In some cases the tablets of vichy taken once or twice 
daily are of great value. 



OTHER FORMS OF SO-CALLED RHEUMATISM. 551 

Other Forms of So-called Rheumatism. 

( Rheumatoid Affections.) 

There are tonus of joint-affectioD which it is not yet advisable 
to class with true articular rheumatism, but which are constantly and 
incorrectly called rheumatic. 

The gonorrheal form of rheumatoid affection is seen in infants 
and children who suffer from gonorrhoea! vulvo-vaginitis or ure- 
thritis (Koplik, Hartley, Moncorvo). It may be monarticular or 
many joints may be affected. It is not, as a rule, combined with 
endocarditis. I know of no such case in the literature. 

Peliosis. — Cases of so-called peliosis rheumatica closely resemble 
acute articular rheumatism. I have seen several in older children. 
In one. there were for weeks repeated painful swellings of the joints, 
with purpuric eruption about them. The gastric pains and critical 
sweats so often seen in rheumatism were present. These cases 
rarely present a temperature above 100.5° F. (38° C). They 
show no cardiac lesion. 

Tonsillitis with Joint-pains and Endocarditis. — Under the 
proper heading I have referred to cases of tonsillitis with indefinite 
pains in the joints and complicated with endocarditis. 

Erythema Nodosum. — I have seen many cases of erythema 
nodosum in children. In all, the typical painful swellings on the 
anterior aspect of the tibia were present. There were also joint-pains, 
but in only 5 cases could I establish the presence of an endocardial 
murmur. I am therefore not willing to accept without reserve the con- 
tention of French authors that endocarditis is frequent in these cases. 

The so-called subcutaneous rheumatic nodules are seen in 
children less frequently in this country than in England. They 
occur in endocarditis, and were present in 20 per cent, of Court's 
cases (I)onkin). They may be present in the absence of fever or 
in the febrile stage of rheumatism. They may be minute or of 
the Bize of an almond. They appear in crops, and may alternately 
appear and disappear for weeks. The nodules occur about the 
joints, elbow-, knees, patella, over the vertebra' and scapula, and are 
freely movable under the skin which is not discolored. I have seen 
them in a case of rheumatoid arthritis, and also in one of peliosis 
rheumatica. 

Muscular rheumatism is rare in infancy and childhood (Jacobi). 
Henoch describes cases of contracture of the muscles of the neck 
and of the nape of the neck. Among such contractures are forms of 
torticollis which are said to have a rheumatic origin. I have met 
many cases of torticollis in which with the contracture there was 
swelling of the cervical lymph-nodes. In such eases I have found 
eczematous affections of the scalp. It is possible thai there was an 
acute infectious neuritis or myositis. There may, however, be cases 
re-ting on a purely rheumatic basis. All forms of torticollis due to 



552 GENERAL DISEASES. 

hsematoma of the sterDomastoid muscles or to cervical bone disease, 
glandular disease, or neuritis should be excluded before a definite 
conclusion is reached. Henoch also refers to contractures of the 
abductors of the thigh which are of rheumatic origin. I have 
never seen cases of the kind. 



DIABETES MELLITUS. 

Diabetes mellitus is of very rare occurrence in infancy and child- 
hood. Simon says that he has met it in nurslings, but Monti doubts 
whether it can occur under the age of one year. In all his experience 
he has never seen such a case. Leroux, quoted by Monti, collected 
147 cases of diabetes in children. The majority occurred between 
the fifth and tenth years. Of 159 cases collected by Saundby, 129 
occurred between these years. Cotton has, in a recent article, shown 
that in children the ratio of deaths from diabetes to the whole death- 
rate is 0.04 per cent, in Chicago, and 1.2 per cent, in New York City. 

The etiology of diabetes in children is practically the same as in 
the adult subject. Frerichs, Blanchard, Parry, and Roberts have 
shown that heredity plays an important role. In a case coming 
under my observation a sister of the patient had died of diabetes 
and four members of the family on the mother's side. In an 
instance reported by Roberts, 8 children of the family had died of 
it. It appears that in certain families there is a tendency to con- 
tract diabetes. There is no ground for assuming that diabetes in 
children follows traumatism or the infectious diseases, such as scarlet 
fever, measles, diphtheria, etc., any more frequently than in the 
adult. In some statistics, the sexes are shown to be equally affected. 
In others the disease is given as more prevalent in one or the other. 
Lemonnis has seen diabetes complicate congenital syphilis, tuber- 
culosis of the lungs and of the mesenteric lymph-nodes. I have had 
a case complicated with tuberculosis of the mesenteric lymph-nodes. 

The symptoms of diabetes in children, as given in the cases thus 
far published, do not extend over so great a period as in the adult. 
The cause of this must lie in the fact that there is a long period 
during which the symptoms are slight or escape notice. In a case 
which recently came under my care the child, nine years of age, 
showed symptoms only five months before she came under observa- 
tion. At that time the mother noticed that the appetite was vora- 
cious and that there were great thirst and frequent urination. In 
spite of the large quantity of food and liquid taken, the child lost in 
weight. The amount of urine passed may be quite large. In Cot- 
ton's case it reached 104 ounces, in mine, 70 ounces daily. Monti 
has seen as much as 16 litres passed in twenty-four hours. Heubner 
and Hirschsprung found that the daily excretion of sugar may be 
from 30 to 113 grammes to the litre. 



DIABETES INSIPIDUS. 553 

In most of the cases recorded there has been polydipsia. The 
skin is the seat of a lichen-like eruption which causes intolerable 
itching. Furuncles and boils are also of common occurrence. The 
urine may contain albumin, and hyaline and granular casts. In 
my case albumin was present, but no easts. There is as a rule 
constipation. The temperature may be normal or subnormal. If 
there is complicating tuberculosis, there will be a slight daily rise 
of temperature toward evening. In all the eases thus far published 
there was progressive emaciation. Acetone in the odor of the 
breath and diabetic coma preceded by intervals of delirium close 
the clinical course of the disease. 

The methods of diagnosis do not vary from those pursued in the 
adult. The urine of a child suffering from polyuria, polydipsia, a 
voracious appetite, pruritus, and progressive emaciation, should be 
carefully examined for sugar. Infants who take foods such as 
malted milk, containing an enormous quantity of sugar, often show a 
temporary glycosuria, which should not be mistaken for true dia- 
betes, and which is not attended by any of the clinical symptoms 
of that disease (Epstein, Koplik). 

DIABETES INSIPIDUS. 

{Polyuria.) 

This is rare in infancy and childhood. If the daily amount of 
urine is three or more times the normal amount, there is polyuria. 
The specific gravity of the urine does not exceed 1006. Ebstein 
collected 10 cases in which the symptoms developed as a result of 
a cerebral inflammation in the vicinity of the fourth ventricle. The 
affection is sometimes hereditary. Cases have followed fright, the 
infectious diseases, meningitis, and traumatism. The cause is fre- 
quently obscure. The onset may be gradual or acute. Sometimes 
intense thirst or nervous symptoms usher in the disease. The nutri- 
tion may be maintained for years. The skin is dry, the body 
temperature below normal, and the symptoms do not differ from 
those manifested in the adult. The following case from my clinic 
was published by my assistant, Dr. Lewi : 

Walter A., aet. -even years, was first seen at the dispensary. The 
family history was, for the most part, negative, except that three 
children had died of uervous diseases, one of them, aged three years, 
of spinal meningitis, and two others, when babies, of convulsions. 
The patient when a baby was healthy ; lie was breast-fed one year 
and had never had a convulsion. When two years old he had vari- 
cella, followed by pertussis ; at the age of five he had measles, com- 
plicated with an obstinate conjunctivitis, but recovered. In Octo- 
ber, 1892, while driving, he was thrown from a carriage in rapid 
motion, striking the right side of the head ; no ill effects were noticed 



554 GENERAL DISEASES. 

at the time. In January, 1893, he began to complain of pain in 
the back and in the nape of the neck. At about the same time 
it was noticed that he arose several times at night to urinate, and 
would invariably drink w r ater after micturition ; the mother noticed 
that he grew very nervous ; the frequent micturition and increased 
thirst gradually became noticeable during the day, becoming so per- 
sistent that he was obliged to leave school. He was placed in a hos- 
pital, where he remained seven months ; while there he lost flesh ; 
none of the symptoms improved. He was on a rigorous milk diet 
during the entire time. 

Status Prcesens. — January 19, 1894, the child complains of pain 
on the right side of his head ; says he feels chilly all the time and 
cannot stand still a moment. His face is pale and has an old person's 
look, with features sharp and pinched. The eyes are large and 
prominent, and the veins of the forehead dilated. The skin is exceed- 
ingly dry. The head is well shaped ; careful palpation shows no 
sensitive spots. The chest is emaciated, with a slight rachitic girdle. 
The lungs, on auscultation give increase of voice-sounds at the right 
apex. The heart is normal, also the abdomen. The epiphyses of 
the ankles are enlarged. The glands at the angles of the jaw are 
enlarged, also those in the left axilla. Urinary symptoms : the child 
is passing a very large amount of urine ; wakens on an average ten 
times a night to do so. The thirst varies with the amount of water 
passed ; for the last few weeks he has complained of painful mictu- 
rition. His appetite is excellent ; he is on a milk diet. Weight is 
thirty-seven pounds ; temperature (per mouth) 97.8° F.. (36.5° C). 
The urine examination was as follows : quantity in twenty -four 
hours, 6400 c.c., colorless ; specific gravity 1.003 ; reaction acid, no 
albumin, no sugar. Microscopical examination negative. 

A series of quantitative urea tests were made in this case. The 
general consensus of opinion is that in cases of diabetes insipidus 
the amount of solids, including the urea, is increased. The tests 
were made with the Doremus ureometer. A control test was always 
made. The table shows marked diminution in the amount of urea. 
In order to avoid error, fresh bromine was used. 



Date. 


Sp. grav. 


Amount in 24 hours. 




Urea. 


Jan. 25. 


1.003 


6.300 c.c. 


6.3 


grammes. 


Feb. 4. 


1.003| 


6.300 " 


6.8 


u 


6. 


1.005 


5.200 " 


7.2 


a 


8. 


1.002 


7.000 " 


6.5 


u 


" 10. 


1.004 


5.500 " 


6.8 


u 


" 17. 


1.002| 


7.500 " 


7.8 


a 


" 24. 


1.003 


6.400 " 


6.5 


u 


Mar. 18. 


1.003 


7.000 " 


8. 


u 


" 30. 


1.003 


7.300 " 


7. 


a 


Apr. 2. 


1.0032 


6.400 " 


6.8 


u 



The treatment has been successful in some respects. The child 
was at once put on a general diet. Antipyrin was given. After the 



DIABETES INSIPIDUS. 555 

first few days there seemed to l>ean abatement of the nervous symp- 
toms and slight diminution in polydipsia, but no permanent im- 
provement. He was then given opium several weeks without result. 
Ergot was next given, and continued for about two months ; under 
this treatment the pain on the right side disappeared ; the restlessness 
became less, and the thirst likewise diminished. Under a generous 
diet the child has held his own ; he still weighs thirty-seven pounds, 
his color is healthy, and the mucous membranes are normal. 

Leaping Authorities Referred to in Chapter IX. 

Biiumler, Ch. : "Gelenk Rheumatismus," Deutsche. Klinik. Bd. ii., 1901. 

Benech : Die gonorrhoische Uelenkentziindung, Berlin, 1899. 

Cotton: "Diabetes in Childhood," Jour. Amer. Med. Assoc., 1901. 

Charcot's works, Arthritis Deformans, New Sydenham edit., vol. iii. 

Hcmsemann, 1). von : Rhaehitis dea Schadels, Berlin, 1901. 

Heubner, 0. : "Rhaehitis u. Versuch mit Sehildriisen Saft zu behandl.," 
Charite Annalen. xxi. 

. .1.: '" Acute Rheumatism in Infancy and Childhood," Amer. Clin. 
Lectures, 1879. 

Kopilh, H. : "Arthritis Deformans in a Child,'' Arch, of Ped., 1896. 

Kjasaowtiz, M. : Rhaehitis, i. and ii. Abtheil, Wien, 1882-5. 

Xormale Ossification. Wien. 1881. 

Symptome der Rhaehitis, Leipz., 1S86. 

Lewi, E. : 'Diabetes Insipidus.'' Arch, of Ped., 1894. 

Miller, J. I). Milton : •"Acute Articular Rheumatism in Infants," Trans. Amer. 
Ped. Soc. vol. xi. 

Moneorvo: "Rheumatism Blennorrhagique Ches. les Enfants," La Med. Infant, 
1894. 

Mont, J. L.: "Rickets," Phila. Med. Jour., 1900. 

"Studvof the Blood in Rickets," Medical and Surgical Report, Boston 

City Hospital. 1897. 

Weal, J. P. : ''Rickets in Eastern Ohio," University Med. Mag., 1895. 

Weil: "Arthritis Deformans," Xouvelle Iconographique, 1890. 

/ <->/>/, P. : Aetiol. Prophylax. u. Therapie der Rhaehitis, Leipzig, 1900. 



CHAPTER X. 

THE LYMPH-NODES, DUCTLESS GLANDS, AND DISEASES OF 

THE BLOOD. 

THE LYMPH-NODES. 

In any disease or irritation of the scalp the nodes of the 
neck may be enlarged behind the border of the sternomastoid. 
The onset of some diseases of infancy, such as rotheln or rubella, 
is indicated by slow enlargement of these glands. Infection of the 
tonsils will cause the lymph-nodes at the angle of the jaw to en- 
large and sometimes to suppurate. In young infants and chil- 
dren, chronic enlargement of the tonsils with adenoids causes an en- 
largement of these nodes. Tuberculous glands may occur in this 
region. The post-auricular lymph-nodes enlarge' in disease of the 
ear or of the adjacent parts of the scalp. Parotitis will cause a 
sympathetic swelling of the lymph-nodes in front of the parotid, 
and also below this gland at the angle of the jaw and beneath it. 

Retropharyngeal adenitis will cause the nodes behind the pharynx 
to swell and to appear at either side of the neck in front of the 
border of the sternomastoid muscle. 

Any eruption on the chin will cause an enlargement of the 
lymph-nodes from the tip of the chin to the hyoid bone. 

Swelling at the angle of the jaw will frequently simulate parotitis 

(Plate XXV.). 

In certain forms of congenital syphilis with mucous patches on 
the lips and at the angles of the mouth (rhagades) there is beneath 
the body of the jaw a symmetrical enlargement of the lymph-nodes 
of both sides (syphilitic adenopathies). The lymph-nodes of the 
groin will enlarge in balanitis of the prepuce, syphilis, tubercu- 
losis of ritual circumcision, and also in eczema and intertrigo of the 
inguinal folds. The lymph-nodes of the femoral region will in 
infants and children enlarge or suppurate as a result of any infection 
of the foot, leg, or thigh. 

In the later stages of tuberculosis, either of the lung or peri- 
toneum, there may be a general enlargement of the nodes of the 
neck, axilla, groin, and elsewhere. In many infants and children 
of a lymphatic diathesis (lymphatism), the nodes of the neck and 
groin show slight enlargement. Such enlargements should not, in 
the absence of positive signs of tuberculosis elsewhere, be hastily 

556 



PLATE XXV. 



r~" 






S- 














V 9 




I 






fc 




% i 


f 


• l 2 

• 
• 


\ 


> 

• 
4 


3 

• 

1 


• • 


i 




£ 












• 


• » 

• 

• 




10 



Topography of Enlarged Lymph-nodes. 

i. Preauricular enlarged, with disease of the external auditory canal, or any eruption on the 
face or parotitis. 

2. Tonsillar node*. 

3. Submaxillary enlarged, with disease of the mouth, or skin eruptions over the lower jaw. 
x. Submental enlarged, with chin eruption-. 

5. Retropharyngeal enlarged, with infections of the pharynx and the retropharynx. 
5. Nodes behind the border of the trapezius muscle enlarged, with disease of the scalp. 
7. Nodes behind posterior border of the sternomastoid muscle enlarged, with infections of 
the retropharynx or the scalp, 
-tauricular node- enlarged, with mastoid <H-< ase or seal]) infections, 
j. Nodes a>. re and behind the clavicle enlarged, with infections of the neck or mediastinum. 
:o. Nodes enlarged in infections of the hand or in eruptions such as those of syphilis. 
[I. Axillary enlarged, with infections of the arm. the axilla and the upper chest. 
12. Nodes of the inguinal region enlarged in infection* of the lower extremity, syphilitic 
or other lesions of the genital-. 



ACUTE ADENITIS. 557 

pronounced tuberculous. After the exanthemata, the lymph-nodes 
of the neck, groin, and other regions may remain slightly enlarged. 
These enlargements usually retrograde to the normal in time, but if 
they remain rarely give rise to symptoms. 

The physician should exclude every possible infection before con- 
cluding that an enlargement of the lymph-nodes in infancy and 
childhood is of a tuberculous nature. Cases of rachitis will show- 
very slight enlargement of the lymph-nodes, especially in the ingui- 
nal regions. Forms of anaemia, such as von Jaksch's disease, also 
show these enlarged nodes. The lymph-nodes may be the seat of 
primary malignant disease, as in forms of lymphosarcomata. In 
malignant growths of the internal organs, such as the kidney, etc., 
they may be the seat of metastatic deposit. They are enlarged in 
acute and chronic forms of leukaemia. In these diseases the spleen 
and liver are also enlarged. 



ACUTE ADENITIS. 

( Acute Lymphadenitis.) 

The lymph-nodes in infants and children are peculiarly susceptible 
to acute infections, which are for the most part pyogenic (staphylo- 
coccic and streptococcic). Van Arsdale collected 500 cases of acute 
lymphadenitis seen in his experience. He found that 77 per cent, of 
them were in children. They are especially liable to the cervical 
infections. Eighty-five per cent, of the cases in children were infec- 
tion- of the lymph-nodes of the neck, the frequency in adults being 
only half as great. 

Etiology. — Most of the infections of the lymph-nodes in chil- 
dren arc according to Van Arsdale, acute (79 per cent.). The ma- 
jority of them are pyogenic. Children are subject to acute infections 
of the scalp, face, mouth, nose, tonsils, and mucous membrane of 
the nasopharynx. The lymph-nodes draining these regions are in 
the direct line of infection. Thus eczema and skin eruptions of all 
kind-, stomatitis of all varieties and inflammation of the tonsils and 
the nasopharyngeal -pace, will give rise to enlargement of the lymph- 
Dodea if the infection is severe, suppuration occurs. It is owing 
to these causes and to the breaches of surface caused by slight trau- 
matism that this form of adenitis is so common. The essential excit- 
ing cause of acute lymphadenitis Is the invasion of the nodes by 
pyogenic bacteria entering through the lymph-channels. 

The symptoms of lymphadenitis in infante and children are 

itially the same as in the adult subject. 'Hie node is at firsl felt 

a- a hard nodular mass beneath the -kin. One node or several may 

be infected. There i- always some fever. At firsl the skin over 

the node i- of normal color, but. a- the inflammation progresses, it 



558 THE LYMPH-NODES AND DUCTLESS GLANDS. 

becomes involved, red, and finally, if not treated, there will develop 
all the signs of an ordinary abscess. 

The diagnosis is not difficult. The history and general course 
at once point to the nature of the disease. When the region about 
the parotid is affected, it is at times difficult to tell whether there is an 
infectious parotitis, or whether the nodes just beneath or above the 
parotid are involved. A preauricular gland situated in front of the 
ear on the parotid gland is apt to enlarge and suppurate. The nodes 
underneath the angle of the jaw and in front of the border of the 
mastoid sometimes enlarge and suppurate, involving the parotid by 
collateral swelling. In all of these cases, it is important to remember 
that a line drawn parallel to the lower border of the body of the jaw 
marks off the parotid above, and the lymph-nodes below. In excep- 
tional cases, the swelling of infectious parotitis may extend lower 
than this line. 

The treatment of acute lymphadenitis is at first abortive. Cold 
applications to the nodes which are enlarged and accessible, such as 
those of the neck, relieve the pain and in many cases lessen the 
severity of the reaction. This result is frequently seen in cases where 
infection of the nodes of the neck results from tonsillitis. Some- 
times, in spite of all that can be done, suppuration occurs as a result 
of infection of cervical, axillary (vaccination), and inguinal nodes. 
In that case, the affected node should be incised. The further treat- 
ment of such cases is surgical. 



CHRONIC LYMPHADENITIS. 

Chronic or subacute enlargement of the lymph-nodes in children 
may be pyogenic, tuberculous, or syphilitic. Of the cases collected 
by Van Arsdale, only 21 per cent, in infants and children were of 
chronic pyogenic origin, as against 1 2 per cent, in the adult. On the 
other hand, only 6 per cent, of all the cases of adenitis in infants 
and children were tuberculous. In the adult, the tuberculous forms 
of lymphadenitis are twice as frequent as in children. It is thus 
seen that even in chronic enlargements of the lymph-nodes of 
infants and children the occurrence of tuberculous forms gives the 
lowest percentage. 

The symptoms of chronic enlargement of the lymph-nodes in 
infants and children are nodular tumors corresponding to the 
affected lymph-nodes. The enlargement may be single or multiple. 
Sometimes a whole packet of nodes is enlarged. The nodes 
most commonly enlarged are those at the angle of the jaw. This 
occurs in infants and children who suffer from chronically en- 
larged tonsils and adenoids. As a rule the nodes affected 
remain enlarged for months. At times they are somewhat less 



DISEASES OF THE THYROID CLAM). 



559 



swollen. They do Dot suppurate unless there is a tendency to a 
breaking-down of tissue. In all of these cases there is not only 
toxie irritation, but also a true hyperplasia of the tissue of the 
glands. I have seen these nodes removed and opened. Some 
of them have a soft, broken-down centre resembling that of the 

tuberculous nodes. 

Tlie treatment of chronic lymphadenitis is directed toward 
removing the source of infection. If the tonsils are enlarged and 
adenoids are present, they should he removed. A tonic course of 
treatment, good food, out-of-door exercise, iron, and cod-liver oil 
is indicated. In spite of these measures many cases do not improve. 
If the enlargement of the nodes in such cases is localized, the question 
of the advisability of removing them arises. That measure should 
not he resorted to unless there is a reasonable certainty that they are 
tuberculous, and when all other treatment has failed. 

DISEASES OF THE THYROID GLAND. 

General enlargement of the thyroid is not uncommon in in- 
fancy and childhood. Normally the thyroid gland, and especially 
its isthmus, can be made out only by careful palpation. The isthmus 

Fig. 156. 




Enlarged thyroid in a child, -ix years old. who Buffered from cardiac palpitation. 

i- indicated by a very slightly raised structure passing across the 

trachea beneath the cricoid cartilage. The lateral lobes cannot be 






560 THE LYMPH-NODES AND DUCTLESS GLANDS. 

palpated. In cretinism and dwarfism, the enlarged lateral or super- 
numerary lobes beneath and just in front of the anterior border of 
the sternoraastoid muscle can be palpated. Cystic growths of the 
thyroid are seen in front of the trachea, generally just above the notch 
of the sternum. They may occur in very young infants or in chil- 
dren of four or five years of age. Enlargement of the isthmus occurs 
chiefly in girls (Fig. 156). In these cases there is a disturbance 
of the heart functions and symptoms of the beginning of morbus 
Basedowii. 

CRETINISM, ENDEMIC AND SPORADIC. 

Cretinism is a chronic affection which is characterized by a de- 
fective growth of the bones of the skeleton in their long axes, accom- 
panied by a distinct set of mental symptoms and by changes in the 
soft parts. 

Forms. — There are two forms, the endemic and the sporadic. 

Endemic cretinism occurs in certain districts of Continental 
Europe. It does not exist in this country (Osier). The pictures 
presented by endemic and sporadic cretinism are similar. Accord- 
ing to the recent studies of Dolega, His, and Bernard, their pathologic 
anatomy is also similar. Endemic cretinism is an advanced rtage 
of a degeneration beginning with goitre manifestations. The result- 
ing changes are due to " athyreosis," a suspension or disturbance of 
the functions of the thyroid gland. Sporadic cretinism, although 
also due to athyreosis, occurs without goitre. The peculiar formation 
of the skull in cretinism, endemic or sporadic, is now known not 
to be due to a premature synostosis of the os basilare and the 
sphenoid, as was at first thought by Virchow. The brachycephalic 
skull as manifested in a broadening of the bridge of the nose, and 
the prognathous expression is due to a deficient growth of the bones 
at the base of the skull, in their long axes. The sutures and fon- 
tanelles remain open for a long time. Dentition is delayed. The 
skin is myxedematous in sporadic cretinism only. Dwarfism and 
anaemia are common to both forms. 

Sporadic Cretinism. 

Occurrence. — The disease may appear in utero or at any time 
after birth. Fully one-half of the cases develop before the eighteenth 
month (Fletcher Beach). 

Symptoms. — I have published cases in which the symptoms 
appeared within a month or five weeks after birth. The history was 
as follows : In one case there was another cretin in the family ; in 
the others there was no such history. The birth as a rule was nor- 
mal (Fig. 157). The infant was jaundiced, but fairly well nourished. 



PLATE XXVI 




Sporadic Cretinism. Child fifteen months of age. 



SPORADIC CRETISISM. 



561 



It lay in a torpid state and was only roused when severely teased. 
The infant was easily chilled. The cry was deep and coarse. The 
forehead was low and narrow. The eyelids were puffy. The 
tongue was large, broad, and thick, at times protruding from the 
mouth. The abdomen was large, and the thighs and legs were out 
of proportion to the length of the trunk. The skin had a greenish 
hue. The thyroid aland could not be found. The surface was cool 
and the rectal temperature <>7° or 97.8° F. (36.1°-36.5° C). The 
blood in these early cases has fetal characteristics. There is no 

Fig. 157. 




Congenital sporadic cretinism. Infant, four weeks old. 



leucocytosis. In the cases which develop some months after birth 
the infant may at first be bright and normal. Six to nine months 
after birth, it may have some slight illness, such as an adenitis, 
and after this the change may be noticed, or the change may 
occur without any preceding illness. The infant ceases to notice 
objects about it, and becomes stupid and weaker. It may previously 
have attempted to walk or stand, but ceases to make an effort to do 
so (Plate WYI.). The child's expression is idiotic. It lias a 
meaningless -mile most of the time and does not play. The >kin 
ha- a wrinkled and myxedematous appearance, the color being not 

36 



562 



THE LYMPH-NODES AND DUCTLESS GLANDS. 



only pale, but also greenish. The nose is flattened, the lips are 
thickened, and the hair becomes dry and sparse. The forehead is 



Fig. 158. 




Sporadic cretinism ; myxoedema marked. Child, twenty months of age. 

narrow and the face has a prognathous expression — " monkey- 
like/' as one mother expressed it. There are no teeth. The neck 
is short and thick. The genitals are large for the age. The skin 



SPORADIC CRETINISM. 



563 



of the scrotum is thickened. The ansemia in these cases is extreme. 
The haemoglobin may be as Low as 18 per cent. (Fleischl). The 
Leucocytes may be as high as 18,000, and the red blood-cells 
5,600,000. 

In other cases, the symptoms are at first more nearly of the myx- 
edematous type. The skin, especially that of the face, has a greenish- 
yellow, waxy, puffy appearance. The upper and lower eyelids are 
swollen, as in nephritis. With these appearances, there are the dry 
hair, the macroglossia, the guttural voice, the dwarfish appearance, 
the protuberant abdomen, and the mental dulness. The expression 
of the face is less prognathous than in the first form. In one of 
my cases, the infant was in good health until the sixteenth month. 

Fig. 159. 




Out '»f the hand of a boy cretin, four years of ace. Flat and spade-like in form: it shows 
also the thickened and hypertrophied hypotnenar eminence. 



It then developed abscesses over the body, after which cretinism set 
in (Fig. 158). The abscesses were peculiar, the granulations slug- 
gish, and the pus was creamy. The skin was not oedematous but 
myxedematous. 

In both forms the hand- are large, Mat, and spade-like. The 
hypothenar eminence is thick, square, and hypertrophied, as in the 
lower animals ( Koplik and Lichtenstein) (Fig. 1 "><)). In some eases 
the thyroid gland cannot be felt, in other- it i> small, and in excep- 
tional eases then- i- goitre (7 cases of Osier's Belies). In some of 

the older cases published, supraclavicular masses of fat or fatty 
tumors behind the sterno-mastoid muscles were found. 1 have failed 

to find them in the cases coming under my notice. 



564 THE LYMPH-NODES AND DUCTLESS GLANDS. 

The etiology of sporadic cretinism is as yet absolutely unknown. 
Experimental and operative pathology have demonstrated that inter- 
ference with the function of the thyroid gland (athyreosis) will 
produce a condition (myxcedema) closely resembling cretinism 
(Horsely, Reverdin, Kocher). The essential cause of endemic cre- 
tinism is thought to be some form of infection (Fagge). Sporadic 
cretinism is also ranked by some authors among the infections. Gull 
and Ord have described the form of myxoedema which develops 
spontaneously in adult life. 

Morbid Anatomy. — There are cases of sporadic cretinism in 
which the thyroid gland is absent. It has not developed in foetal life 
and is not found at autopsy. In other cases there is found at autopsy 
a small atrophied gland which is sclerosed and much reduced in size. 
Such cases have been published as following the infectious diseases. 
Lastly, there are cases with goitre. The changes in the thyroid, 
when it is found in sporadic cretinism, have been described by 
Barker. There is an increase of connective tissue. The paren- 
chyma is replaced by small and large irregularly shaped cells, which 
are granular and unlike the normal tissue. Some of the acini are 
almost solid ; others are cystic and filled with colloid material. The 
cells may contain vacuoles ; their nuclei may show " karyorrhexis." 
The nuclear changes are characteristic of degenerative processes. 
Some of the acini are replaced by connective tissue. 

The Bones. — In the recent work of His, Dolega, and Bernard, it 
has been clearly shown that ossification in the pre-existent cartilagi- 
nous structures of the skeleton is delayed in all its phases. This is 
evinced in the delayed appearance of ossification centres, the delayed 
bony transformation of the epiphyses, and in the persistence of the 
epiphyseal zones. In some cretins, ossification is completed at a very 
late period of life ; in others, infantile conditions are perpetuated. 
The dwarfing of the whole skeleton is thus explained, not by a pre- 
mature synostosis, but by faulty proliferation and ossification of the 
epiphyseal cartilages. The bones of the skull are affected in the 
same manner as the vertebrae and the long bones, in that they fail to 
grow to their long diameters and in that ossification centres appear 
late. 

The diagnosis is not difficult in advanced cases. The early cases 
require close study. In these, the stupidity increasing to absolute 
idiocy, the retarded growth, the change in the expression, the swol- 
len eyelids, thick lips, dry hair, wrinkled myxedematous skin, the 
flat, spade-like hands, the dwarfish appearance, and the reduced 
internal temperature, all point to the diagnosis. In later cases, the 
extreme anaemia, myxoedema, and pronounced prognathous expres- 
sion of the face are apparent. 

Sporadic cretinism must be differentiated from the following con- 
ditions : 



PLATE XXVII. 




Mongolian Type of Idiocy. Child two years of age. 



FCETAL RICKETS, OR ACHOXDROPLOSIA. 565 

Mongolian Idiocy. — This is a form of gcnetous idiocy with which 
cretinism is frequently confounded. The idiots resemble cretins. 
The growth is stunted. The mouth is kept open. The tongue is 
large and fissured ; the papillae of the tongue are enlarged and 
erect. The tongue protrudes from the mouth (Plate XXVII.); the 
lips are thick ; the voice is coarse and guttural. The temperature may 
be subnormal, but is generally normal. The skin is dry and the hair 
coarse. In young infants the skin may be delicate. The patients are 
easily chilled. The musculature is flabby. The infants cannot hold 
the head erect. The occiput is flattened, the neck short and thick. 
There is strabismus, and the axes of the eyelids have a Mongolian 
slant — that is to say, they converge. The inner eyelid comes down 
toward the nose with a rapid slope 1 . The bridge of the nose is flat. 
The head is small and obtusely rounded ; the antero-posterior diam- 
eter is nearly equal to the lateral one. The fontanelles remain open 
late. The skin, however. i> not my x< edematous, nor is the expression 
prognathous as in the cretin. The anaemia is as a rule marked ; 
in some cases the skin has a greenish hue. There is a curving inward 
of the tip of the little finger. The second phalanx is short and the 
terminal phalanx displaced. West has shown that although this 
deformity is very common in these idiots, it is not pathognomonic of 
Mongolian idiocy. Many of the subjects grow to adult life and have 
some degree of intelligence. 

The Dwarf with Idiocy. — There may be several of these dwarfs in 
a family. The thyroid gland is enlarged at the beginning or during 
the course of the condition. The mental state is much stunted. The 
general growth of the body is retarded. The dwarfs are, however, 
well formed. The hands and extremities arc perfect and the skin 
is not myxoedematous. 

Infantalism combined with lipomatosis may be confounded with 
cretinism. In this form of disease there is no myxoedema and the 
skin i- very delicate and -oft. The genitals are atrophied. The 
expression of the face is that of child-like simplicity, the forehead 
i> low and narrow. The hair is dry, and does not grow; the 
finger-nail- do not grow. There may be, as in the case I published, 
blindness. The mental state is one of mild idiocy. 

Foetal Rickets, or Achondroplosia. 

I < ' 'hnuilrmliislriijihiii FcBtolis.) 

- have been reported in this country by Jacobi, Smith, 
and Town-end. Thomson, of England, has described the affec- 
tion as of intra-uterine origin. Although Horsley and Barlow 
classify the cases with sporadic cretinism, they should, for clinical 
purposes, be regarded as a separate set. They have nothing in com- 
mon with rachitis or cretinism (Thomson). The patients arc far 



566 THE LYMPH-NODES AND DUCTLESS GLANDS. 

from being idiotic or presenting any of the symptoms of myxoedema. 
Some of the dwarfs who reach adult age are exceedingly clever. 
Many of them are performers in museums and are above the average 
in intelligence. The case published by Townsend was that of a 
stillborn infant. 

Parrot and Jacobi have described infantile cases. The affec- 
tion is due to absence, arrest, or perversion of the normal process 
of endochondral ossification in every bone in which it takes place 
in utero. 

The treatment of cretinism constitutes one of the most marvel- 
lous chapters of modern medicine. The administration of thyroid 
extract results in a partial restoration of the mental capacity 
and a return to growth and development approaching the nor- 
mal. I published in 1897 some cases of cretinism diagnosed early 
in infancy, in which the treatment was begun at once. In those in 
which the treatment was begun at the age of one month, the chil- 
dren have become bright and apparently normal. In those in which 
it was inaugurated at the fifteenth month, the children have, after 
five years of treatment, remained somewhat backward in mental 
development. One patient, now a boy of six years, goes to school 
and recites his alphabet, but is very simple in manner. In these late 
cases the treatment does not give the complete results at first expected. 

I begin with the dried extract, grain J (0.03) t. i. d., and 
increase the dose until the infant takes a grain j (0.06) three 
times daily. After the symptoms have retrograded, the dosage 
is kept stationary for a few months. It is then reduced or the remedy 
is given only every other day. If symptoms, such as stupidity, pallor, 
or reduced temperature, reappear, the dose is increased. The first 
sign of improvement is a reduction of the ansemia, as evidenced in the 
increase of haemoglobin. The body temperature rises to the normal. 
The skin becomes of normal delicacy and supple. The stature in- 
creases and the hair becomes glossy. Thomson, of Edinburgh, 
has published cases of adult cretins whose bones became softened 
after the prolonged administration of thyroids. These were cases in 
which treatment was begun late in life. The symptoms of excessive 
administration of thyroids include rise of temperature and slight 
diarrhoea. 

I have found thyroid therapy of doubtful utility in cases of Mon- 
golian idiocy. In the dwarfs above mentioned, it causes increase of 
stature ; the intelligence, however, remains backward. 

THE THYMUS GLAND. 

Landmarks. — The thymus is a glandular organ enclosed in a 
capsule. It is situated in the anterior mediastinum, and contains a 
white tenacious fluid substance which is present in varying quanti- 



HYPERTROPHY OF THE THYMUS. 567 

ties. Sappey shows that the thymus in the newborn infant extends 
from the upper edge of the manubrium sterni, 5 cm. downward. Its 
upper border may reach the isthmus of the thyroid or may be removed 
2J cm. from it. It extends downward to the middle or upper third 
of the pericardium. In exceptional eases it may have a longitudinal 
diameter of 11 \ cm., reaching the diaphragm (Triesethau). The 
thymus is about 2 to 3 cm. wide. Luschka makes it unsymmetrical, 
consisting of two lobes united by an isthmus. It lies over the 
course of the pulmonary artery and is surrounded by a reflection of 
the pericardium. It is separated from the sternum by loose con- 
nective tissue. Its length varies from 4 cm. in the nursling, to 11 
cm. in the ninth year, the average ratio to the body length being 1 
to 7 or 8. 

Weight. — Its weight varies. In the results which I obtained 
in collaboration with Jacobi, it did so within wide limits. In infancy 
the average weight is 20 grammes ; from the second to the fourteenth 
year it is 24 grammes. After the twenty-fifth year the thymus atro- 
phies and may weigh 2.2 grammes (Friedeleben). In abnormal 
states the weight may be 32 grammes (Triesethau, Pott). The 
causes of the enlargement of the gland and the conditions under 
which it occurs are not as yet known. The gland is large in infants 
dying of the most diverse diseases. 

Percussion. — Under the most favorable conditions it is difficult 
to ascertain the exact size. The thymus has sometimes been marked 
out as large during life, and post mortem found to be small. As a rule, 
an area of dulness situated oehind the upper part of the sternum, and 
discernible on gentle percussion, may be cautiously interpreted as due 
to the thymus (Sahli). An unsymmetrical area giving dulness on 
one side of the sternum is probably due to the thymus (Luschka), 
especially in subjects under the second year. 

Abnormal Conditions. — None of the abnormal conditions of the 
thymus can be diagnosed with certainty during life. 

Hypertrophy of the Thymus. 

Hypertrophy of the thymus has been observed by Virchow, 
Grawitz, Pott, Jacobi, and others. The symptoms caused by the 
exceptional enlargement have been grouped by Virchow, Grawitz, 
West, and Goodhardt as a symptom-complex which is described in the 
literature under the heading of "Thymic Asthma." Many cases un- 
attended by a form of laryngismus stridulus and difficult breathing, 
and eventuate in convulsions and sudden death. There lias been 
much discussion as to the existence of thymic asthma. It has been 
doubted that sudden death can be caused by a large thymus. The 
conclusion of Virchow, Grawitz, Pott, and others, thai it may do so, 
must be accepted. In the case of Pot! the thymus weighed 32 



568 THE LYMPH-NODES AND DUCTLESS GLANDS. 

grammes, was 9 cm. long and 1 J cm. thick. By compressing the 
upper air-passages, the large venous vessels, the right ventricle, or 
the recurrent nerves, an enlarged thymus may cause sudden death. 
That possibility is denied by Friedeleben. In the work of Jacobi, 
it was shown that hemorrhages of the thymus are not uncommon, 
and are present in a number of conditions, especially in pertussis. 
Inflammation of the thymus may be present in inflammatory condi- 
tions of the pleura and pericardium. Steudener has published a case 
of sarcoma of the thymus, and Yogel one of carcinoma of that organ, 
occurring in childhood. Demme published a case of isolated tubercu- 
losis of the thymus. In the monograph of Jacobi, general tubercu- 
lous infection of the thymus was investigated, as was also the con- 
dition as found in diphtheria. In the latter disease, I have found 
the same condition of necrobiosis of the thymus described by Oertel 
as occurring in other organs. Congenital syphilis may manifest 
itself in arterial and connective-tissue changes. Abscess of the 
thymus is rare. 

THE SPLEEN. 

Anatomical. — At different periods of childhood the length of 
the spleen varies from 4 to 10 cm., the breadth from 2 to 5 cm., 
the average thickness being about 0.5 cm. It forms an oval-shaped 
body, behind the ninth, tenth, and eleventh ribs, the long axis running 
in the direction of the ribs. Up to the second month of life, the an- 
terior edge of the spleen is found in the midaxillary line ; after that, 
it may be found further forward than this line, or posteriorly to it. 
The upper edge corresponds to the upper edge of the ninth rib ; the 
lower border to the lower border of the eleventh rib. The spleen 
may be located by percussion and palpation. 

Percussion. — The patient is caused to lie on the back. It is not 
necessary to cause children to lie in an inclined lateral posture. 
The upper border is first located by percussing from above down- 
ward in the midaxillary line on the left side. At the seventh rib 
is a strip of slight dulness extending from the seventh to the ninth 
rib (Fig. 95). I have been able to locate it in infants and in chil- 
dren under the age of six years. There can be no question as to its 
existence, although there may be doubt as to its causation. Symming- 
ton, in his frozen section, shows that, in a girl six years of age, the left 
lobe of the liver is distinctly on the left side behind the seventh and 
ninth ribs. Sahli ascribes the strip to what he calls the deep dulness 
of the spleen. From the ninth rib downward, there is absolute 
dulness, then flatness, due to the presence of the spleen proper 
behind the chest wall. The anterior border of the spleen is located 
by percussing in a horizontal direction toward the axillary line along 
the tenth rib. 



THE SPLEEN. 



569 



Palpation. — The enlarged spleen can be distinctly made out 
by palpation. The abdomen should be relaxed. It is sometimes 
accessary to Hex the thighs slightly, in order to relax the abdomen. 
In young infants it is not necessary. 

The physician stands at the right side of the patient and with the 
palmar surface of the fingers of the right hand palpates the abdom- 
inal parietes just beneath the border of the ribs (Fig. 160). As the 
patient inspires deeply, the hand is by steady pressure insinuated be- 
neath the ribs in an upward and backward direction. In the vast 
majority of cases under the tenth year, the normal spleen may thus 
be felt. 

In practice, it may safely be said that a spleen which cannot be 
felt below the border of the ribs is not enlarged, unless some con- 
dition, such as the presence of fluid or tympanites, prevents thorough 
palpation. I have rarely failed to palpate the enlarged spleen 



Fig. 100. 







Method <>f palpating the spleen. 

satisfactorily. Enlargement of the spleen is found in rachitis, 
chronic gastro-enteritis, sepsis, typhoid fever, malarial fever, vari- 
cella, syphilis, anaemia infantum pseudoleuksemica, leaukaemia, con- 
genital syphilis, cirrhosis of the liver, amyloid degeneration, heart 
disease, and simple catarrhal jaundice. 

From these statements it will be seen that enlargement of the 
spleen iu infancy and childhood is pathognomonic of no one disease, 
and should not lead to any one conclusion. It is only corroborative 
in the presence of other signs and symptoms. Without a very 
thorough and painstaking examination of the blood, the significance 
of the enlarged spleen in the febrile and afebrile affections cannot 
be determined. In enlargements of the spleen such as are met 
in rachitis, heart disease, syphilis, chronic gastro-enteritis, icterus, 
varicella, examination of the blood may not be necessary. 



570 THE LYMPH-yOBES AyB BUCTLESS GLANDS. 

Splenic and Kidney Tumors. 

In rare cases in which sarcoma of the left kidney is suspected, 
It may be necessary to exclude tumor of the spleen. 

An enlarged spleen is smooth on the surface and has a sharp 
anterior edge interrupted by an indentation — the hilus. The tumor 
is pointed and sharp below. It can be grasped deep in the lumbar 
region behind. 

Kidney tumors are irregular on the surface and marked out into 
lobes, some of which may be cystic. The tumor projects upward 
behind into the lower part of the chest. The whole lumbar region 
is flat on percussion. The borders of the tumor are rounded. On 
the other hand, I have made an autopsy in a case of cirrhosis of the 
liver and spleen in which the latter organ during life showed 
uneven tumors on its surface (gummata). The physician must 
be partly guided by the history of a case. The urine should be 
examined in cases of sarcoma of the kidney, and the blood in cases 
of enlarged spleen. I have seen a subphrenic abscess displace the 
spleen downward. The left lobe of the liver was also displaced 
in the same direction. Under anaesthesia, a round mass could be 
felt above the spleen, which was enlarged. Behind, the lung came 
well down to the bottom of the chest, as was evinced by the presence 
of the respiratory murmur. Dulness was, however, present in the 
left axillary line and behind. On exploratory puncture in the poste- 
rior axillary line, the subphrenic abscess was found to be present. 



THE BLOOD. 

LEADING GENERAL CHARACTERISTICS OF THE BLOOD 
IN INFANCY AND CHILDHOOD. 

For diagnostic purposes, it is important to bear in mind certain 
characteristics of the blood in infancy and childhood. Ehrlich has 
shown that conditions normal to the blood in early life are of grave 
import if found in the adult. 

The Red Blood-cells — the Erythrocytes. — During the first three 
days of life, nucleated red blood-cells are found in the normal blood. 
In the newly born infant, the red blood-cells number from 4,500,000 
to 6,500,000 to the cubic millimetre (Hayem). There is a polycy- 
themia. This condition is found during the first few days of life. 
On the fourteenth day there is an average of 5,500,000 red blood- 
cells to the cubic millimetre. From the second to the tenth year 
the average number is 5,000,000 (Otto, SchhT, Sorenson). The 
polycythemia in the newly born infant is greater if the tying of 
the umbilical cord is delayed until its pulsations cease. Weaklings 



BLOOD IN INFANCY AND CHILDHOOD. 571 

show a diminished number of red blood-cells. In addition to 
imperfect nutrition, anaemia of any kind, acute or chronic cachexia, 
and certain drugs, such as antipyrin, antifebrin, phenacetin, and 
lactophenin, reduce the number of red blood-cells by disintegrating 
a certain proportion of them (Monti). Infectious diseases, such as 
malaria, scarlet fever, typhoid fever, and sepsis, have a similar 
influence. In severe anaemia, such as that accompanying rachitis, 
nucleated red blood-cells appear in the blood. These are also 
found in the severe primary anaemias, in acute leukaemia, and 
in pernicious anaemia of infants and children. 

The White Blood-cells — the Leucocytes. — The number of 
leucocytes in the newly born infant is high, being from 18,000 to 
30,000 to the cubic millimetre (Hayem, Guppen). It gradually 
falls to 12,000 to the cubic millimetre, the average for infants. 
The percentage of lymphocytes is at first small in comparison with 
that of the polvnuclear leucocytes. Gundobin, whose work has been 
confirmed by Carstanjen, found that the polvnuclear leucocytes pre- 
ponderate in the newborn infant. They increase and reach their 
highest figure in the first forty-eight hours of life. They then 
diminish in number, while the mononuclear lymphocytes increase 
proportionately until the seventh or tenth day, when the blood 
assumes the characteristics which distinguish it during the period of 
infancy. During infancy the mononuclear lymphocytes are more 
numerous than the polymorphonuclear leucocytes. The following 
table is taken from Gundobin's figures : 

Polymorpho- 
nuclear Mononuclear Transitional 
leucocytes. lymphocytes. forms. 

Immediately after birth . .63 percent. 25 per cent. 12 percent. 
Fortv-eisdu hours afterbirth. 70 " 21 " 19 " 

Infancy 34.6 " 59 " 6.4 " 

In normal infants and young children, the number of leucocytes 
to the cubic millimetre may vary from 13,000 to 20,000 (Japha). 
The so-called digestive leucocytosis found in the adult is inconstant 
in infants and young children (Japha). There is undoubtedly an 
inflammatory leucocytosis in infants and children similar to that seen 
in the adult. It occur- in pneumonia, measles, scarlet fever, rheu- 
matism, sepsis, diphtheria, post-hemorrhagic anaemia, and cachexia 
(sarcoma). In the normal state, the leucocyte- may reach a mini- 
mum of 6000 t<> the cubic millimetre (Monti). This fact should be 
borne in mind in estimating the leucopoenia in typhoid fever, malaria, 
tuberculosis, and in other infection- or toxic Btates. 

The transitional forms of leucocyte- are numerous in the newly 
born infant, reaching their maximum from the sixth to the ninth 
day. The eosinophiles are present in the same number as in later 
life (Japha). 

The Haemoglobin. — The blood i- richer in haemoglobin at birth 



572 THE LYMPH-NODES AND DUCTLESS GLANDS. 

than later in life (Morse, Leichtenstern, Rotch). After birth the 
percentage of haemoglobin sinks, and at the third month reaches that 
of later life. Carstanjen found the haemoglobin to reach on the 
average 100 per cent, up to the twelfth day. The lowest percentages 
are found from the sixth month to the second year. There is, in 
exceptional cases in normal children, a very high percentage from 
the fifth to the tenth year, ranging from 95 to 110 (Widowitz, 
Leichtenstern, Hock, and Schlessinger). The percentage in healthy 
children may be as low as 60 (Fleischl) or 8.4 grammes to 100 c.c. 
of blood. At the third month of infancy it may range from 69 to 
94 ; up to the second year it may range from 62 to 81 (Monti). 
There seems to be no fixed normal limit. Anaemia or toxaemia 
of any kind and infectious diseases diminish the haemoglobin. 

The Specific Gravity. — The exact clinical significance of the 
specific gravity of the blood is little understood. The specific 
gravity is high in the newly born infant, ranging from 1.056 to 
1.066. From the sixth month to the tenth year it varies from 
1.050 to 1.056 (Monti). These figures correspond to those of 
Hock, Schlessinger, Lloyd, Jones, and others. The blood of strong 
children and breast-fed infants has a higher specific gravity. Diar- 
rhoea may raise it, but rarely to a ratio of more than 0.004 part per 
1000. The specific gravity is increased in the infectious diseases, 
pneumonia, pleuritis, endocarditis, typhoid fever, and tuberculous 
meningitis, and falls on the decline of these processes. It is also 
increased in congenital heart disease, chorea with endocarditis, icterus, 
and diphtheria. It diminishes with the loss in weight accompanying 
anaemia and nephritis, and in cachexia (Hock, Schlessinger, Monti, 
Hammersley, and Fel sen thai). 



ANiEMIA. 

Anaemia is a condition resulting from a deficiency in the blood of 
one or more of its constituent elements. It may be either congenital 
or acquired. In the latter case it may either be secondary to other 
conditions or occur as a primary disease. Congenital anaemia is 
seen at birth in infants born of badly nourished mothers, who dur- 
ing pregnancy have suffered from some disease of the placenta, or 
from syphilis, tuberculosis, or malaria. The foetus in utero becomes 
anaemic. Acquired anaemia appears after birth. It is either sec- 
ondary to some acute loss of blood (post-hemorrhagic), to chronic 
loss of blood, or is caused by defective nutrition, unhygienic sur- 
roundings, diseases of the various organs, toxaemia, infectious diseases, 
or parasites. 

Primary or essential anaemia is the form in which the changes in 
the blood play so important a role that it is assumed there is a dis- 






SIMPLE ANJSMIA. 573 

ease of the blood itself or of the blood-forming organs (Monti). 
Such are the forms of leukaemia, chlorosis, and pernicious anaemia. 

Simple Anaemia. 

(Secondary Anaemia.) 

Secondary simple anaemia may follow some acute or chronic loss 
of blood. In acute post-hemorrhagic anaemia, the increase of fluid 
elements keeps pace with the loss of blood if the loss, though small, 
is repeated at short intervals. Children show the effects of loss of 
blood much more quickly than adults. Hydremia is the condition 
which results when the loss is marked. The fluid elements increase, 
and there is a diminution in the specific gravity of the blood and in 
the amount of haemoglobin. Hydremia may result in children with- 
out hemorrhage: that i- to say, it may occur in extreme severe 
anaemia secondary to some disturbance of nutrition or to illness. In 
post-hemorrhagic anaemia the coagulability of the blood is increased 
immediately after the hemorrhage. Ehrlich supposes this to be due 
to an increase in the number of blood-plates. After the hemorrhage, 
the regeneration of blood is in the infant, as in the adult, indicated 
by the formation or appearance in the blood of microcytes, megalo- 
cytes, and nucleated red blood-cells (normoblasts). The severe forms 
of this variety of anaemia also show polychromatophilic properties of 
the red blood-cells. These are so poor in haemoglobin that with 
various -tains the normal reaction is very much changed. There are 
various -hades of the stained red blood-cells. In recent and severe 
g . of post-hemorrhagic anaemia there may be leucocvtosis. There 
is an increase of the polynuclear neutrophilic leucocytes (Monti, 
Ehrlieh). Nucleated red blood-cells (normoblasts) may appear in 
severe cases. Poikilocytosis is also one of the changes seen in the 
blood. 

Secondary anaemia of a mild or of a severe type is also seen in 
infants and children who suffer from defective nutrition. It com- 
plicates or accompanies rachitis, syphilis, scrofula, tuberculosis, gastro- 
intestinal catarrh, chronic endocarditis, purpura, morbus Werlhofii, 
and infectious diseas< 

The symptoms of mild anaemia in infants and children do not 
differ materially from those of adults. The patient is pale and the 
mucous membrane- have a characteristic pallor. The appetite is capri- 
cious. The pati<nt- also suffer from symptoms due to the primary 
affection — syphilis, rachitis, acute infectious disease, gastro-enteric 
disturbance (acute or chronic), or cardiac affection. The pallor of 
cardiac disease or nephritis i- characteristic in infants and children, 
a- in the adult. 

The anaemia if of a severe type takes the hydraemic form. In 
the severer form- of anaemia, especially in infant- and very young 



57-1 THE LYMPH-NODES AND DUCTLESS GLANDS. 

children who suffer from syphilis or rachitis, the skin is waxy white 
or yellowish. The ears are absolutely devoid of any color of 
blood. In cretinism the skin has a greenish -yellow hue. Infants 
do not show the symptoms, such as dyspnoea or palpitation, seen 
in older children on exertion. The muscles are flabby and there 
is a disposition to lie quietly in the crib. The spleen may be 
large, and the liver also, especially if rachitis or syphilis is present. 
In cases in which the anaemia is extreme, the spleen may be 
normal. 

Infants and very young children do not always show the anaemic 
murmurs which are heard over the heart area in older children. In 
older children murmurs of that variety may be present with a 
venous hum in the neck, and the symptoms of mild and severe 
anaemia are essentially those of later life. These are indisposition 
to exertion, feelings of weakness, drowsiness, lack of appetite, irri- 
tability, and restlessness. Some of the severe forms of anaemia show 
for weeks a very slight irregular febrile curve. In many cases the 
fever is due to intestinal toxaemia. 

The Blood. — The mild forms of simple anaemia may show only 
a diminution in the amount of haemoglobin, a very slight diminution 
in the number of red cells, a reduction of the specific gravity, and if 
there is a primary affection which, like pneumonia, causes an increase 
in the number of leucocytes, leucpcytosis. My records of severe 
forms of anaemia in infants and young children show a diminution 
in the amount of haemoglobin (18 per cent.). The blood shows 
microcytes, megalocytes, megaloblasts, and normoblasts. Increase 
of mononuclear lymphocytes is proportionate to that of the poly- 
nuclear leucocytes. Poikilocytosis in various forms is present, as are 
also polychromatophilic phenomena. In the severe forms of anaemia 
due to malarial poisoning I found, in addition to the plasmodium, 
microcytes, megalocytes, and megaloblasts. The eosinophiles are not 
increased. In severe anaemia, the physical characteristics of the blood 
are striking. It may be so thin as to separate on puncture into 
a reddish and a colorless portion resembling beef-water. 

Chlorosis. 

Chlorosis is a form of primary anaemia. It is not a disease of 
infancy or childhood, and is mentioned here only in order to complete 
the classification of diseases of the blood. Its etiology is obscure. 
Virchow believed it to be due to congenital narrowness of the 
whole arterial system and smallness of the heart. This theory 
does not explain the cases in which recovery takes place. Meinert 
ascribed the condition to an irritation of the abdominal sympathetic. 
Hofman thought that developmental conditions of the genital ap- 
paratus were causal in chlorosis. Forcheimer contends that intestinal 



PSEUDOLEUK^MIC ANMMIA OF VON JACKSCH. 575 

auto-infection is etiological in producing the chlorotic state, since 
there is in chlorosis an interference with the production of haemo- 
globin, the principal source of which is the gut. 

Occurrence. — Chlorosis is more common in females than in 
males, and occurs at the time of puberty. 

The condition of the blood has been described by Monti. The 
haemoglobin is diminished. The number of red blood-cells is in 
mild cases scarcely at all reduced. In severe cases it may fall to 
1,000,000 to the cubic millimetre. The absolute amount of haemo- 
globin may reach 4 to 8 in 100 cubic millimetres of blood. The 
specific weight may be reduced to 1035. There are microcytes in 
the blood. There is do Leucocytosis. There are poikilocytosis and 
polychromatophilie appearances in the stained blood. 

Pseudoleuksemic Anaemia of von Jaksch. 

(Ancemia Infantum Pseudoleukcemica.) 

In 1889 von Jaksch described a symptom-complex met with 
among infants and young children, to which he gave the name of 
anaemia infantum pseudoleukaemica. He described the condition as 
a clinical entity which, in running its course, gives the picture of 
severe lymphatic anaemia. There are enormous enlargement of the 
spleen, slight enlargement of the liver, some enlargement of the 
lymph-nodes, and changes in the blood. It is a secondary anaemia 
rather than a distinct disease. For this reason Fischl, Epstein, and 
others deny that it is a clinical entity. On the other hand, Monti 
and Luzet have described numbers of cases. I have records of 5 
cases, 1 of which was published. The anaemia is extreme. 

Etiology. — It is difficult to determine the etiology. Yon Jaksch 
and Monti trace an intimate connection between this condition and 
rachitis. Wentworth and others regard it as secondary to some 
form of intestinal infection. 

Occurrence. — The condition is rarely found before the age of 
six months. My cases ranged from the ages of twelve to eighteen 
months. It may occur up to the third year, and is most common 
from the seventh to the twelfth month. Most of the cases thus 
far published have occurred in infants or children suffering from 
rachitis or congenital syphilis. In all of my eases there were signs 
of rachitis. Some of the children had previously suffered from 
chronic gastro-enteric derangement. 

Morbid Anatomy. — The spleen is large and fills the left hypo- 
chondrium. sometimes reaching the crest of the ilium. It is hard, 
smooth, and has a sharp bonier. There is an increase of the 
cellular element-. A small number of haemoglobin-bearing cells of 
the -ize of red blood-cells are found. 

The liver is slightly larger than is normal, but is of normal 



576 



THE LYMPH-NODES AND DUCTLESS GLANDS. 



consistency and color. The lobuli are less distinct than is nor- 
mal. Lnzet has described cellular elements in the liver containing 
finely granular protoplasm. These are not like liver cells. They 
have small sharply defined nuclei , sacculated in shape. They are 
surmised to be forerunners of the red blood-cells. The liver cells 
are normal. The lymph-nodes are only moderately enlarged, and do 
not form lymphomata, as is the case in leukaemia. There are no 
changes in the bone-marrow. 

Symptoms. — The infants affected have as a rule suffered from 
chronic intestinal disturbances. Most of them are bottle-fed and 
atrophic. Although the skin is intensely anaemic and of a yellow, 

Fig. 161. 




Pseudoleuksemic anaemia, enlarged spleen and liver. 



waxy tinge, there is sometimes a panniculus of fat. The musculature 
is flabby and the abdomen large. As a rule there are signs of 
rachitis. The fontanelle is open and the eruption of the teeth delayed. 
The infants are irritable, peevish, do not willingly take food, and do 
not assimilate it. In one of my cases, there was complicating pneu- 
monia. 

There is, as a rule, no fever, unless it is due to intestinal toxaemia. 
The picture is one of progressive emaciation and anaemia. In some 
cases there is complicating icterus, and the spleen reaches to the crest 
of the ileum. The edge of the spleen is sharp and the hilus can be 
distinctly felt. The liver is slightly enlarged ; its edge is round and 






LEUKJEMIA (LEUKOCYTRJSMIA). 577 

smooth. Iu one of mv cases, it extended two and one-half inches 
below the tree border oi' the ribs (Fig. 161). The lymph-nodes in 
the groin and axil he are slightly enlarged, sometimes only to the 

o 0.0/ * 

size of a bean. 

The Blood. — The specific gravity of the blood is reduced. The 
haemoglobin may be reduced to one-quarter the normal percentage. 

It maybe as low as 17 percent. (Fleischl). There is a marked 
diminution of the number of red blood-cells. The nucleated forms 
of erythrocytes are abundant. There are megaloblasts, which show 
karyokinesis. In addition there are red blood-cells of all sizes — 
microeytes and megalocytes. There is poikilocytosis to a marked 
degree, and also polychromatophilia. The leucocytes are only 
moderately increased. In the severe cases the proportion of white 
blood-cells to the red may be as 1 : 100, 1 : 80, or 1 : 15 (Monti). 
The picture given by the leucocytes is different from that of leu- 
kaemia. Most authors agree that the various forms are represented 
and increased in equal ratio. In my cases' the mononuclear lympho- 
cytes, as well as the transitional forms, were increased. 

The course of the disease is chronic. In most cases, the chil- 
dren succumb to progressive weakness and emaciation, or to inter- 
current disease. Recovery may take place. I have seen one case 
of aggravated form improve under treatment. AVhether these cases 
can, as stated by Monti, pass into a leukaemia or pernicious anaemia 
i> a matter of doubt. 

Treatment. — Thus far the treatment has been empirical. Small 
doses of Fowler's solution are indicated. If rachitis is present, 
phosphorus is given by some in small doses. I have seen cases do 
badly under that treatment. Tonics and an easily assimilable diet 
are indicated. The bowels should be kept clear by enemata given 
daily in order to lessen the possibility of infection of the gut. 

Leukaemia (Leukocythaemia). 

Leukaemia i< a persistent condition of the blood in which there is 
an increase of the white blood-cells, and a diminution of the red 
ones. It i- a primary disease of the blood itself. Accompanying it, 
there are changes in the spleen, liver, bone-marrow, lymph-nodes, 
and lymphoid tissues. Virchow called the condition " white 
blood." French writers have called it leukocythaemia. The pro- 
portion between the white and the red blood-cells is not so distin- 
guishing ;i feature as the appearance of large numbers of* lympho- 
cyte- in the blood, in which they are normally present in only small 
number-. In one form the appearance of mononuclear neutrophile- 
staining myelocytes which are normally absent is a distinguishing 
feature. Ehrlich characterize- leukaemia as a mixed Leucocytosis of 
chronic course, since white blood-cells of all kinds arc present in 
37 



578 THE LYMPH-NODES AND DUCTLESS GLANDS. 

the blood. This is not the case in the polynuclear and eosinophile 
leucocytosis. 

Occurrence. — The disease is rare in childhood, but some 
authors believe it to be more common in the first year of life than 
is generally supposed (Monti, Mosler). Fifteen to 20 per cent, of 
the cases occur in the first decade of life (Baginsky). Males are 
more frequently affected than females. The disease is believed to be 
hereditary. 

The etiology of the affection is still unknown. In a few cases, 
micro-organisms and sporozoa have been found in the blood (Roux, 
Kelsch, Veillard, Lowit). The sporozoa of Lowit are described by 
him as being free in the blood as well as in the leucocytes and in 
the blood-making organs. In lymphatic leukaemia they are described 
as being intracellular only. 

Some writers think that rachitis and syphilis predispose to the 
development of leukaemia, especially if the bones are involved as 
well as the liver, spleen, and lymph-nodes. Certain forms of 
anaemia following malaria, diphtheria, and scarlet fever, and accom- 
panied by enlargement of the liver, spleen, and lymph-nodes, may, 
according to some writers, pave the way for leukaemia. Physical or 
mental strain, unhygienic living, defective nutrition, and traumatism 
of the spleen, have all been regarded as predisposing factors. 

Forms. — The simplest classification of leukaemia is that based 
upon the anatomical appearances of the blood. Such is the classifi- 
cation of Ehrlich, which is as follows : 

(a) Lymphatic leukaemia, in which there is a marked hyper- 
plasia of lymphoid tissue. 

(6) Myelogenous leukaemia, in which there is hyperplasia of 
myelogenous tissue. Lymphatic leukaemia may run an acute or a 
chronic course. In both forms the distinguishing feature is the 
appearance in the blood of large numbers of the mononuclear lym- 
phocytes and the displacement of the polynuclear leucocytes. The 
acute form is rare. It occurs in childhood. Four cases have 
occurred in my hospital service in the past two years. It's course is 
rapid. There are slight or marked tumor of the spleen, slight or 
very marked enlargement of the liver, and a tendency to petechia? 
and to general hemorrhages. Some authors regard these cases as 
infectious. The chronic forms show marked enlargement of the 
spleen. 

Changes in the Blood.— As was previously stated, the lym- 
phatic forms of leukaemia are distinguished by the appearance, in the 
blood, of large numbers of the small and large mononuclear lympho- 
cytes. In the myelogenous forms, a cell which is normally not 
present in the blood, but is indigenous to the bone-marrow, appears 
in large numbers. This cell is the large mononuclear neutrophilic 
staining cell, the myelocyte of Ehrlich. The mast-cells are also 



LEUKAEMIA (LECKOCYTILEMIA). 579 

found in these cases, but are not peculiar to this form of anaemia. 
In addition there is in the myelogenous forms of leukaemia an 

increase in the number of all three types of granulated white cells, 
the neutrophiles, the eosinophils, and the mast-cells. There are 
dwarf forms of the white blood-cells, mitoses, and lastly large num- 
bers ot' nucleated red blood-cells. Normoblasts, megaloblasts, and 
myelocytes are not normally present in the blood. They are occa- 
sionally found in pneumonia, and in ieucocytosis. The eosinophils 
are increased to fifteen times their normal number. The slow 
coagulability of leuksemic blood is characteristic. 

The spleen is enlarged. It is at first soft, often firm, and is 
infiltrated with lymph-cells. The capsule is thickened ; the connec- 
tive-tissue stroma is increased and infiltrated with lymph-cells. The 
lymph-nodes show similar changes, and may be enlarged, forming 
tumors of considerable size. 

The bone-marrow is so infiltrated with lymph-cells as to acquire 
the appearance of a purulent infiltration. The same lymphoid infil- 
tration is found in the liver. The follicles of the gut are swollen. 
There is an increase of lymphoid cells and tissues. The lymphoid 
tissues elsewhere, such as the tonsils, thymus, skin, and even the 
retina, show the same changes. There are hemorrhages and exu- 
date in the ear, and the nerves and nervous tissue of the central 
nervous system are the seat of lymphoid cellular invasion. 

Symptoms. — Acute Leukaemia. — Cases of acute leukaemia in 
infancy and childhood have lately been increasing in the literature. 
The most recent cases include those of McCrae, in a boy aged 
three years, and of Miller, in an infant of eight months. Cases 
have also been reported by Morse, Japha, Strauss, Monti, Berggriin. 
The symptoms in all the published cases were similar. In a boy eight 
year- old, admitted to my hospital service, there were 1 no premonitory 
symptoms. Two month- before admission he was in good health. 
He became very pale, there were irritability and loss of appetite, and 
the abdomen increased markedly in size. He complained of pains 
in the leg-, and at the onset had chills and fever every other day. 
After the appearance of the chills he suffered from a low irregular 
fever. A week before death, the skin had a waxy color, there were 
petechia- on the extremities, the gums bled easily, and the lvmph- 
noded of the axillae and groin were enlarged. There was an anaemic 
murmur with the first sound of the heart ; the liver was enlarged 
below the free border of the rib- to the extent of two fingers' breadth ; 
the spleen Was enlarged to the level of the umbilicus ; the fundus 

of the eye showed retinal hemorrhages. Examination of the blood 

showed the haemoglobin to be reduced t<> 15 per cent. (Fleisclil ). 
The red blood-cell- numbered 1,012,000 to the cubic millimetre j 
the white blood-cells, 37,000. There was an immense prepon- 
derance of lymphocytes (mononuclear). The patient died with 



580 THE LYMPH-NODES AND DUCTLESS GLANDS. 

signs of progressive weakness. Coma was preceded by vomiting 
and the appearance of a few petechia?. The blood state continued 
much the same as at first. In another case the number of mono- 
nuclear lymphocytes was fully 75 per cent, of the white blood-cells. 
In both these cases the spleen and liver diminished before death. 
The proportion of white to red blood-cells may not be far from 
normal. In another case the nucleated red blood-cells, large and 
small, were very numerous. In this case, in a boy of five years, 
the nodes around the parotid and angle of the jaw, in the axilla, 
and in the inguinal region, increased in a short time to a large size, 
and the spleen grew rapidly larger and reached to the crest of the 
ilium. The liver reached to the umbilicus. These mediastinal 
lymph-nodes were enlarged and caused great dyspnoea. The dis- 
tress Avas very great just before the lethal issue. In a case of 
v. Xoorden's the proportion of the white to the red blood-cells was 
1 : 200. The character of the white blood-cells is diagnostic. 
Most of the cases published showed a slight temperature. The 
fa tul issue usually results a few weeks or a month or two after the 
onset of symptoms. 

The Chronic Form. — The symptoms of the chronic form extend 
over a greater length of time. For months there are anaemia, lassi- 
tude, and extreme physical weakness. The appetite is good, but in 
spite of abundant nourishment, emaciation is progressive. In some 
cases there are periodic diarrhoeal attacks. Profuse hemorrhage 
may occur without warning either from the nose or intestines. 
Chills and fever resembling those of paludism are sometimes present. 
None of these symptoms is particularly characteristic. As the dis- 
ease progresses there are headache and pain in the limbs and 
in the region of the spleen. The anaemia after a time assumes a 
severe type, and the skin becomes waxy and yellow. At this stage 
the spleen and liver enlarge and distend the abdomen. There 
are dyspnoea and palpitation ; the anaemia takes the hydraemic form, 
and there is oedema of the face, hands, and feet. Hemorrhages then 
occur from the nose, lungs, month, intestines, but rarely from the 
kidneys. There are petechiae in the skin and hemorrhages in the 
retina. In the lymphatic form the lymph-nodes in various parts of 
the body enlarge and form masses which are painless and covered 
with unaffected skin. The skin may be affected by the process. 
The mesenteric nodes may sometimes be felt through the abdomen. 
The spleen attains an enormous size. The liver may extend as far 
as the umbilicus. Respiratory difficulties, heart weakness, and 
nervous symptoms (such as vertigo, somnolence, and coma) end the 
clinical course of the disease. The urine is diminished, and con- 
tains hyaline casts, lymphoid cells, and a trace of albumin. There 
may be a slight continued fever in the course of the disease. 

The prognosis is very unfavorable. Of 39 cases collected by 






STATUS LYMPHATICUS. 581 

Birch-Hirschfeld, only 4 recovered. Only in the early stage is 
recovery possible. Death supervenes from exhaustion with hemor- 
rhages or from intercurrent pleuritis or pericarditis. 

The treatment of a disease whose exact nature is still unknown 
i> difficult. Good food, and hygienic surroundings are the first 
requisite. In the treatment of" anaemia, the iodide of iron, cod-liver 
oil. and arsenic are the chief drugs employed. In the lymphatic 
form, arsenic in the form of Fowler's solution gives the best results. 



STATUS LYMPHATICUS. 

■iiphatism ; Lymphatic Constitution.) 

This condition should be differentiated from those described 
under the heading of Scrofulosis. Thus far it has been described 
only in infants and young children. Although its existence lias 
been known for a long time, it has only lately been discussed by 
Paltauf, Pott, and Eseherieh, abroad, and by West, Rachford, and 
Crandall, in this country. The condition is found chiefly in children 
who are subject to rachitis and moderately wel] nourished but amende. 
They have enlarged lymph-nodes at the angle of the jaw, in the 
axilla, and in the groin, and are also subject to attacks of laryn- 
gismus stridulus. They have enlarged tonsils, adenoid tissue in the 
posterior nares, and enlargement of the adenoid tissue at the base of 
the tongue. On the other hand, they present none of the skin, bone, 
and joint-affections -ecu in the scrofulous or tuberculous subject. 
Eseherieh has published cases in which there were thirty attacks of 
laryngospasm a day. The patients also have symptoms of increased 
excitability of the peripheral motor nerves, such as Trousseau's phe- 
nomena and Chvostek's symptom. I have had one casein which 
there was an attack of laryngismus at every crying spell. The pa- 
tients are in constant danger of' sudden death. Several fatal cases 
have occurred (Eseherieh, Pott, Welt). Post-mortem examination 
in all of these cases showed that with the signs of hyperplasia of 
lymphatic tissue above mentioned there was enormous development 
of the thymus. Such were the cases of Langerhans, Paltauf, and 
Eseherieh. In the ease of an infant who died suddenly in the Mount 
Sinai Hospital (Sara Welt), not only was the thymus enlarged to an 
enormous degree, but also the lymphatic tissue of the gut was the 
-eat of great hyperplasia. The question of the cause of sudden 

death in these eases is a much mooted one. The old theory of ptf 

lire on the bronchi or the laryngeal nerves is now generally aban- 
doned. Pott and Eseherieh have recently suggested that death i- 
not caused by a Bpasm of the larynx or respiratory muscles, but by 
heart failure or syncope. Eseherieh has advanced the theory that 
the pathological condition of the thymus gland is the cause of a species 



582 THE LYMPH-NODES AND DUCTLESS GLANDS. 

of auto-intoxication, which on the least provocation manifests itself 
in a tendency to cardiac syncope and paralysis. 

The treatment consists in the removal of the enlarged tonsils 
and adenoids. In my case, as in that of Crandall, the condition of 
lymphatic node enlargements was vastly improved by the operation. 
Good food, cod-liver oil, and the preparations of iron which contain 
iodine, are also indicated. 

THE HEMORRHAGIC DIATHESES. 

In this class of diseases are embraced only those affections which 
are due to some primary change in the blood or in the circulatory 
apparatus. Thus conditions which are due to local disease of some 
organ, or the hemorrhages which follow the acute infectious diseases 
or drug poisoning are not included. Experimental pathology has as 
yet not given any clue to the etiology of the hemorrhagic diatheses. 
The contention of William Koch and Ajello, that they are infectious 
diseases or are due to some auto-intoxication, is not universally ac- 
cepted. At present the clinical classification of these diatheses into 
the transitory forms in which are included purpura simplex, peliosis 
rheumatica hsemorrhagica, scorbutus, and the persistent form heredi- 
tary in character, such as haemophilia, may be accepted. In the 
latter, the hemorrhage may be extensive, difficult to control, and due 
to some very slight cause. 

Simple Purpura. 

This is a transitory condition characterized by small hemorrhages 
or petechia?, or large, irregularly shaped extravasations of blood. 
These are as a rule discrete, but may be confluent, and are situated 
in the epidermis or in the superficial layers of the cutis. Imme- 
diately after the extravasation they have a bluish-purple tinge. After 
a few days they become brown or greenish yellow. These extravasa- 
tions are seen most frequently on the lower extremities, generally 
on the extensor surface. They also occur in other localities. As a 
rule there are few or no symptoms. There may be crops of petechia? 
appearing at short intervals. In a few cases there are, after an exacer- 
bation of the local phenomena, loss of appetite, vomiting, and general 
malaise. The so-called purpura cachecticorum appears on the body, 
abdomen, back, and upper extremities in children under two years, 
suffering from diarrhoea and other exhausting diseases. In the latter 
case there may be leucocytosis, due to the original affection. The 
changes in the blood in simple purpura are still to be studied. 

Etiology. — The cause of this purpura is still unknown. It may 
be due to some obscure toxaemia. 

The prognosis is very good in the primary form. In the second- 
ary form it will depend on the nature of the original affection. 



PLATE XXVIII. 




Haemophilia. Boy six years of age. Haematoma of the face; 
hemorrhage into the knee-joint. (Case of Dr. Martin Ware.) 



BJBMOPHILIA. 5^83 

The treatment will depend on the nature of the original disease. 
I treat the purpura itself in the same manner as eases of purpura 
hemorrhagica, which will later he fully described. 



Haemophilia. 

Haemophilia is a rare condition which may be congenital or 
hereditary. It becomes apparent at birth or in early infancy, and 
is rare in later life. 

The nature of the affection is obscure. It is a type of hemor- 
rhagic diathesis which is transmitted from generation to generation 
in the female line. It is characterized by the occurrence of uncon- 
trollable hemorrhage after very slight injuries, and operations, and 
also in the absence of known traumatism. 

Etiology. — Many theories of the cause of the affection have been 
advanced. They may be grouped as follows : 

{<i) An abnormal delicacy and friability of the bloodvessels. 

{h) An increase of the volume of blood (Immermau). 

{r) A defect in the coagulable constituents of the blood. 

((7) Certain agencies acting as toxins on the elements of the 
blood, causing their dissolution (Koch). 

The condition is most common in the Slavic races. Children 
♦ lying of the affection show evidences of intense anaemia, but may 
be well nourished. Virchow has demonstrated that there is a nar- 
rowness in the arteries and also a thinness of their walls. Birch- 
Hi r>chfeld found that the endothelium of the arteries was enlarged, 
and that the nuclei were swollen. The blood itself shows no 
changes except those proper to post-hemorrhagic anaemia. The 
hemorrhages may occur in any region and from any organ of the 
body. There may be hemorrhage into joints, profuse epistaxis, 
intestinal hemorrhage or uncontrollable hemorrhage from the mouth 
or lung. The drawing of a tooth, the incision of an abscess, or a 
minor operation such as circumcision, may cause uncontrollable and 
fatal hemorrhage. In the newly born infant, there maybe fatal 
hemorrhage from the cord. In the case pictured in Plate XXVIII., 
there were hemorrhages into the joints and into the face, without 
distinct traumatism. This case came of a family of bleeders in 
which there had been fatalities following circumcision. 

The condition lasts week-, months, or years — in fact, it persists 
during the life of the individual. Some authors believe that the 
female members <>f families thus affected should not marry. 

The treatment is mainly prophylactic. The infant should 
nurse a wet-nurse, in order that the noxious influence of its own 
mother's milk may be lessened, (rood food and fruits of all kinds 
should be given. All operations and traumatism should be care- 
fully avoided. 



584 THE LYMPH-NODES AND DUCTLESS GLANDS. 

Purpura Hemorrhagica. 

(Morbus Maculosus Werlhojii.) 

In the prodromal period before the appearance of the hemor- 
rhages, there may be several days of general malaise, disturbance of 
appetite and digestion, and febrile movement. There are anaemia, 
pain in the limbs, and oedema of the feet. The hemorrhages may 
appear without any symptoms. They are especially frequent in 
the lower extremities, and next most frequent in the upper extremi- 
ties and on the chest, face, and trunk. They consist of extrava- 
sations of blood in the skin and subcutaneous tissue. The mucous 
membranes are frequently affected. Epistaxis, bleeding of the 
gums, bloody movements, and bloody urine result. There are 
ecchymoses in the conjunctiva and bleeding from the ear. The 
hemorrhages in the skin may be petechiae, or irregular bluish or 
purple blotches which subsequently become yellowish or greenish 
yellow. They occur spontaneously or follow slight traumatism or 
pressure. There may be hemorrhages into the joints. There may 
be exacerbations and recurrences of hemorrhages extending over 
weeks. The tendency of the mucous membrane to bleed has been 
mentioned. The gums are spongy and bleed easily. There are 
hemorrhages or petechia? on the soft and the hard palate. The 
hemorrhages from the kidney cause the appearance of albumin 
and blood in the urine. The urine is red and blood-coloring 
matter may be found by the turpentine-guaiac test. Hemorrhages 
in the brain and central nervous system may occur, causing paralyses 
and coma. In mild cases there is no disturbance of nutrition, but 
in severe ones the uraemia is marked, as is also the emaciation. 
The blood shows few changes. The number of red blood-cells is 
diminished, as is also the specific gravity. In severe cases there is 
a slight leucocytosis ; the polynuclear leucocytes are increased, 
eosinophiles are few, microcytes are present, and there are a few nor- 
moblasts. The leucocytosis improves as recovery sets in. 

Course. — The cases of ordinary severity recover. Severe cases 
may recover or may result fatally. 

The etiology of this affection is still obscure. Because of its 
infectious nature, William Koch believes it to be allied to scorbutus 
and other hemorrhagic affections. His view is not supported by 
other writers. Ajello and Schwab regard the condition as an auto- 
infection or a form of toxaemia. Kolb, Tizzoni, and Babes have 
found bacteria in the blood of fatal cases. Others have isolated 
streptococci and staphylococci from the blood (Lebreton). In one 
of my cases there was a history of an insect-bite. The disease is 
rare in breast-fed infants and is more common after the age of two 
years than before. The infants and children attacked may have 
previously been in good health. 






PURPURA RHEUMAT1CA. 585 

The diagnosis is made from the course of the affection and the 
size and nature of the hemorrhages. The constitutional disturbance 
is more marked than in simple purpura. The hemorrhages are 
blotches, in that respect differing from the petechias of peliosis. 
The joints are not swollen, as in the latter affection 

The treatment consists in placing the patient in hygienic sur- 
roundings, and giving a nutritious diet with a liberal allowance of 
fruit and vegetable acids. In marked cases, Fowler's solution, 
given in moderate doses, gives good results. 

Purpura Rheumatica. 

{P<:lio-<i.< Rheumatica of Schbnkin.) 

Purpura rheumatica consists of an eruption of small discrete 
purpuric spots in the vicinity of the large joints of the extremities, 
and occurring especially on the lower extremities above the knee. 
The accompanying symptoms are pain and swelling of the joints 
of the lower or upper extremities. 

Symptoms. — Slight fever is followed by the appearance of the 
purpuric spots and the -welling of the joints of the lower and rarely 
of the upper extremities. The joints are painful, as in rheumatism. 
At times the swelling of the joints is less apparent, but there is 
nevertheless tenderness on pressure. The purpuric spots are partic- 
ularly numerous in the vicinity of the joints. A general urticaria 
may precede the appearance of the purpura. There are no heart 
complications. The condition of the blood is not as yet understood. 
There may be several crops of purpuric spots appearing at intervals 
of days or weeks. In other cases there are oedema of the face and 
enlargement of the spleen. In one of my cases there were at first 
slight hemorrhage- from the bowel. There may be epigastric pain 
and tenderness in the course of the disease. 

The average duration of the affection i> from ten to fourteen days. 
There may be relapses extending over weeks. 

The etiology i< obscure. The disease occurs in children pre- 
viously healthy. It is seen in older children only, and has no ap- 
parent relation to acute articular rheumatism. 

The prognosis is good even when there are several relapses and 
when the affection take- a subacute course. 

Treatment. — Rest in bed is the first requisite of treatment. A 
nutritious diet in which there is an abundant allowance of fruit and 
vegetable acids is given. Lemonade and orange-juice are especially 
indicated. The bowel- are regulated with the salicylate <»f sodium 
given in moderate doses. A child four years of age i- given grains 
v (0.3) three time- daily. The pains in the joints are easily con- 
trolled by rest. In the subacute stage -mall doses of Fowler's 
solution are of great benefit. 



586 THE LYMPH-NODES AND DUCTLESS GLANDS. 

Henoch's Purpura. 

Henoch in 1874 described a series of 4 cases of purpura which he 
classified as distinct from purpura hemorrhagica or peliosis rheumatica. 
The symptoms were as follows : Children apparently in good health 
were attacked by a form of purpura in which there were arthritic 
pain, vomiting, and intense abdominal pains with bloody diarrhoea. 
The rheumatoid pains were accompanied by swelling of the joints. 
The purpura was of the hemorrhagic type — that is to say, there 
were extravasations of blood in the form of ecchymoses or raised 
exanthematic areas, not disappearing on pressure. The areas were 
situated on the abdomen and lower extremities. The joints affected 
were those of the wrist, elbow, and ankle. The intestinal symptoms 
consisted of repeated vomiting, tympanites, excruciating colicky 
pains, bloody stools, and tenesmus. One case was fatal. Such 
cases have been from time to time described by other observers. I 
have seen a case in a young infant, which ended fatally. These cases 
are at present regarded as due to a form of intestinal infection the 
exact nature of which is still obscure. They constitute a group 
probably belonging to the class of primary hemorrhagic affections in 
which is included the so-called peliosis rheumatica. 

Diagnosis of Forms of Purpura. — It is not always possible, 
clinically, to assign each form of purpura to its proper class. This 
is especially true with young children, in whom there occur forms 
of purpura showing a diversity of symptoms and not fitting into 
any sharply defined class. Nor is it always possible at the bedside 
to decide whether the condition present is scorbutus or idiopathic 
purpura. Characteristic of both purpura and scorbutus are the 
hemorrhages into the skin, the internal organs, the serous cavities, 
and the mucous membranes. On the other hand, the frequency of 
hemorrhages and affections of the gums, the prodromal cachexia, 
the joint-affections, and the periosteal hemorrhages are peculiarly 
characteristic of that form of scurvy called Barlow's disease, which 
is seen in nurslings and young children. The purpuric affections of 
so-called idiopathic type, in which a purpuric exanthema is spread 
over the whole surface, may be called simple purpura. 

In the so-called rheumatic purpura or peliosis rheumatica there 
is a blotchy hemorrhagic exudate over the surface in the vicinity 
of the joints, with pain in the joints, and gastric pains. There is 
always a tendency to relapses. Hemorrhages from the mucous 
membranes and bowels are rare, but occasionally occur. 

In purpura hemorrhagica or morbus Werlhofii there are minute 
or blotchy hemorrhages in the skin and internal hemorrhages from 
the mucous membranes, stomach, and intestines. Attempts to 
define sharply each of these sets of cases have been made. It is 



PERNICIOUS ANAEMIA. 587 

nor always possible or desirable to do so. I have seen eases of 
peliosis with bowel hemorrhages and gastric crises, and eases of 
purpura hemorrhagica in infants, in which there were pains in the 
joints, evinced by the distress shown when the joints were moved. 
The forms of purpura regarded by Henoch as a distinct type are 
classed by others as purpura rheumatics. The different classes of 
idiopathic purpura therefore overlap, one case frequently showing 
symptoms of two types. The only possible conclusion is that there 
may be a common cause of all forms of purpura — probably an in- 
fection. 

PERNICIOUS ANJEMIA. 

This is a primary anaemia which causes progressive impoverish- 
ment of the blood and results in death. It is not common in 
infancy and childhood. The condition of the blood in infancy and 
childhood has not as yet been closely studied. The changes in the 
blood which have been published as characteristic of this condi- 
tion in infancy and childhood are found in other states, such as the 
severe anaemia of rachitis and syphilis. Ehrlich is not disposed to 
accept these cases without question. Blood pictures which in the 
adult may be diagnostic of pernicious anaemia cannot be thus in- 
terpreted when found in infants and young children. Observers 
of note, such as Monti, Berggrun, and Baginsky, have published 
cases in infants and young children. I have met a case in an 
infant which had been bitten by a rat. After an interval, anaemia 
of a progressive and fatal type set in. The changes in the blood 
were similar to those characteristic of the same form of anaemia in 
the adult. Monti has collected 16 eases, 2 of which were in in- 
fant- ; 5 ranged from one to six years ; J) were above the age of 
five year.-. On the other hand, Ehrlich found that of 240 authentic 
cases, only 1 occurred in the first decade of life. That ease was in a 
L r irl of eight years. In the face of such great diversity of opinion, it 
is wise t<» await the results of further research. For the purpose of 
reference, the following account of the change- in the blood which, 
according to Ehrlich, are diagnostic of pernicious anaemia in the 
adult, is appended : 

(a) The volume of blood is markedly diminished. 

{!>) The color i- ;it first normal, but latei- resembles that of beef- 
water. 

(<•) The haemoglobin maybe a- low as 10 per cent. (Fleischl). 
This i- due to a diminution of the number of vm\ blood-cells, for 
the individual cell may have a haemoglobin content equal to the 
normal or above it. 

(<1) Th<rc are microeytes, megalocytes, and sometimes giganto- 
cytes. The megalocytes may constitute ~ (| per cent, of the red 



588 THE LYMPH-NODES AND DUCTLESS GLANDS. 

blood-cells. They become fewer on convalescence. There are few 
mega lob lasts, but characteristic normoblasts are found. 

(e) Clumps of free granules are found in the blood. The red 
blood-cells may contain granules. 

(/) Staining solutions produce polychromatophilic effects. 

(g) The eosinophils are normal in number. 

(h ) The number of white blood-cells is diminished as well as 
that of the polynuclear neutrophiles. The latter condition indicates 
serious involvement of the bone-marrow. The lymphocytes are 
proportionately increased. 

(£) The leucocytes show no changes. Improvement is ushered 
in by leucocytosis. 

(j) The specific gravity of the blood is diminished, as is also its 
coagulability. 

In my case the nucleated red blood-cells were numerous. 



INFANTILE SCORBUTUS OR SCURVY (Barlow). 

(Acute Rachitis (Moleer) ; Barloxu's Disease, Hemorrhagic Rachitis (Furst) ; Scurvy 
Rickets (Cheadee) ; Hemorrhagic Periostitis (Smith). 

History. — Cases of this affection are described in the literature 
under the name Acute Rachitis, which was given by Moller, 1859— 
1862. The first definite clinical description of the disease under 
its present title was made by Barlow. Cheadle, Gee, and others of 
the English school, completed its clinical study. Northrup and 
Crandall have made it familiar to American physicians. 

Occurrence. — The disease occurs chiefly in infants and in chil- 
dren under the age of two years. Under certain conditions it also 
occurs in older children and in adults. The majority of the 372 
cases collected by the committee of the American Pediatric Society, 
occurred between the sixth and fourteenth months. The ninth 
month showed the greatest percentage of the cases occurring before 
the end of the second year. The sexes were equally affected. A 
second attack was recorded in a case of Holt's. In a case which I 
saw recently, there were two attacks. 

The Nature of the Affection. — The nature of scurvy as it is 
seen in infants and children is still obscure. It is undoubtedly a 
form of hemorrhagic diathesis, Avhich attacks subjects susceptible 
because of previous abnormal constitutional conditions and defective 
nutrition. There are several theories as to its exact nature. None 
is universally accepted. Some insist that it is a form of acute 
rachitis (Moller, Forster, Bohm, Steiner, Furst, Ausset). Others 
contend that it is a form of scorbutus (Barlow, Northrup, Crandall, 
Xetter, Rehn, Pott), Some of the English school regard it as a 
combination of scurvy and rickets (Cheadle, Gee, West). To the 



INFANTILE SCORBUTUS OR SCURVY. 589 

latter contention Heubner, Schoedel, and Nauwerck give most sup- 
port. These authors insist that the disease supervenes only in an 
organism already affected by slight or marked rachitis. On the other 
hand, there are authors who, like Schmorl and Xaegeli, think that the 
affection is sui generis. Some authors have endeavored to establish 
a correlation with congenital syphilis. The consensus of clinical 
opinion, however, tends toward the acceptance of the theory of the 
scorbutic nature (^' the affection. 

Etiology. — The essential exciting cause i< not yet known. The 
theory of the toxseniic or infectious nature of the disease has been 
advocated by William Koch. Bacteria of various kinds have been 
found in the blood, but there is little uniformity in the results of 
studies. In all the cases thus far studied the nature of the diet, 
breast-milk, raw cows' milk, sterilized or pasteurized milk, or some 
artificial food, has been a strong predisposing factor. The diet has 
been insufficient for the nutrition of the patient, but what special 
element has been lacking in the food is still obscure. In the collected 
results of the investigations of the American Pediatric Society 10 
infants were wholly breast-fed; 2 were partially breast-fed; 4 took 
raw milk. The greater number, 68, were brought up exclusively 
on sterilized milk : 16 took pasteurized milk. The others took 
foods of different kinds. It may be that the mode of preparing the 
food (raw cows' milk, pasteurized or sterilized milk) is of less im- 
portance in paving the way for the onset of this affection than its 
inherent composition. Cases have been cured in part by changing the 
composition of the food, also by substituting sterilized for pasteurized 
food, and vice vers". The very fact that breast-milk has been the 
exclusive article of diet in some cases should direct attention to the 
fact that the affection may be caused by lack of some necessary 
element in the diet. This view is commonly taken at present. It 
is interesting in this connection to consider the contention of the 
celebrated Arctic explorer Nansen, that if exercise and fresh air are 
taken, and abstinence from alcohol i< maintained, scurvy on voyages 
will be unknown if foods are carefully sterilized and devoid of toxins 
and ptomains. The latter, he insists, exist in most of the milk, fish, 
and f<>od eaten on voyages. Although in the most aggravated cases 
of* -curvy that have come under my notice the diet has been steril- 
ized milk, many infant- who take that food prepared properly do not 
develop the disease. Souk- authors believe that the sueee^s of anti- 
scorbutic treatment with vegetable acid- indicate- that the organism 
ha- been for a time deprived of some essential food element. In the 
presence of a concrete case attention should first be directed to 
securing fresh food of proper composition. 

Rachitis. — Much ha- been -aid as to the connection of rachitis 
with this disease. The investigations above referred to show that fully 
45 per cent, of the cases occurred in infant- and children who 



590 THE LYMPH-NODES AND DUCTLESS GLANDS. 

showed clinically signs of rachitis. This does not account for cases 
in which rachitis may exist, but may not be apparent except on 
microscopic examination (Hirschsprung, Schoedel). The majority 
of cases examined post mortem showed the changes of rachitis 
(Schoedel, Schmorl). 

The morbid anatomy has been carefully and extensively 
studied by Schoedel, Nauwerck, and Schmorl, whose results agree in 
all essentials. 

The bones in most cases show the changes seen in rachitis. 
There are disturbances of growth and of bone formation. There is 
an increase in the width and vascularization of the cartilage zone. 
There are irregularity of the calcification zone, and a pathological 
formation of osteoid tissue. The changes at the epiphyseal junc- 
tion and the periosteum are those seen in rachitis. The ribs are the 
bones most frequently affected, the next greatest frequency being in 
the bones of the lower and upper extremities. The changes caused 
by scurvy consist of hemorrhages into the loose vascular layer of 
connective tissue of the periosteum adjacent to the bone. Thus the 
hemorrhages are intraperiosteal and not subperiosteal, as was for- 
merly supposed. They may be of considerable extent, either in the 
vicinity of the epiphyseal junction or in course of the shaft of the 
bone. They may form a layer several millimetres or centimetres in 
thickness. The outer layer of the periosteum, the fibrillar connective- 
tissue strata, is not the seat of hemorrhage, except in the severest 
cases. The layer of periosteum next the bone is thickened. The 
hemorrhages are both recent and old. Hemorrhages of both kinds 
are found in the medullary canal. The morbid changes are most 
marked in the ribs, next in the femur and in the bones of the upper 
extremities. Some of the long bones show loosening and even sepa- 
ration of the epiphyses and diaphyses. The infractures or fractures 
are of this nature. The fragments may override. In such cases the 
hemorrhage is great. The marrow of the bones loses its lymphoid 
character and becomes gelatinous. 

There are subpleural and subepicardial hemorrhages. The spleen 
is enlarged, owing to the presence of rachitis. Slight subcuta- 
neous hemorrhages may extend into the muscular tissue. There are 
hemorrhages into the mucous membrane of the hard palate and gums. 

Symptoms. — Mild cases sometimes escape notice. An anaemic 
infant may cry when bathed or may favor one extremity. It may 
hold one thigh rigid or cry when the limb is handled in the process 
of diapering. Mothers at first suspect traumatism. The infant 
develops slight ecchymoses on the tibiae, and is then brought to the 
physician. If there are teeth, there may at this stage be no swelling 
of the gums or of the extremities. There is no fever ; there may 
not be any anaemia. In the severer cases the symptoms are more 
marked. The skin in the infant of from seven to nine months 



X 

x: 
x 

< 




INFANTILE SCORBUTUS OR SCURVY. 591 

of age acquires a pallid or greenish tinge. The infant cries when 
touched. One or both of the lower extremities lie as if paralyzed. 
If an attempt is made to move them, the infant appears to feel pain. 
The limb is swollen in the course ot' the shaft or in the vicinity of 
the knee or ankle, the swelling extending up the shaft (Plate XXIV.). 
The ribs are apparently tender. There may be one or two subcu- 
taneous ecchymoses on the surface of the body. If there are teeth, 
the gums, especially those of the upper jaw, are swollen into cushion- 
like formations. These bleed easily and may partly conceal the teeth. 
If there are no teeth, the gums may appear normal, or the free bor- 
der, especially of those of the upper jaw, may have a bluish, swollen 
appearance, which may be very slight or quite marked. The infants 
may have a capricious appetite, may take little of the bottle or may 
nurse ravenously. 

The very severe cases have, as a ride, been allowed to run on for 
months in the belief that the infants were suffering cither from rheu- 
matism or dropsy. For some time before coming under treatment, 
the infant has cried when diapered or when the shoes or stockings 
were put on ; later it becomes pale and loses ground. The appetite 
is poor. The thighs and the ankles begin to swell. The child does 
not move the extremities, which are swollen to twice or three times 
the original circumference. Ecchymoses appear on the surface of 
the swellings of the legs and thighs. Parts of the skin acquire a 
bluish-green, bruised appearance. Deformity occurs in the thigh, 
especially at the junction of the diaphysis with the head of the bones. 
This is due to ihfracture or loosening of the epiphyses at the epiphy- 
seal line. The costochondral junction of the ribs is much swollen. 
There is a distinct series of very large swellings in this locality 
which arc due to hemorrhage into the line of juncture of the rib and 
cartilage. Ecchymoses and sugillation appear about the orbit. The 
face and eyes have an (edematous, hydraemic appearance. The 
gum- may not be at all affected, but if the infant has teeth there 
may be sponginess. 

When the physician examines the infant, he finds that the pain 
produced by the procedure causes it to shriek with agony. The 
ribs an- painful to the touch. The swellings on the thigh are uni- 
formly fusiform, and, as a rule, hard and not fluctuating. The ab- 
domen is tense and tympanitic;. The infant has had some bleeding 
from the nose, but not necessarily from the bowel. In other cases 
there are not only hemorrhage- from the bowels, but also from the 
kidney, in the form of haanaturia. There may be albumin and casts 
in the urine. 

The pulse is as a rule not increased. In one case without com- 
plicating pneumonia, in which I found the respirations enormously 
increased, I reached the conclusion that the increase was due to the 
pain and extreme anaemia. 



592 



THE LYMPH-NODES AND DUCTLESS GLANDS. 



In severe cases there may be a slight temperature (Fig. 162), 
which may be due to resorptive fever caused by the immense 
extravasations of blood. 

The hemorrhages in the skin may be localized in the form of 
minute petechiae or there may be ecchymotic blotches of considerable 
size. The latter may appear over the swellings along the bones. 

The fractures or infractions were present in only 9 cases of the 
set collected by the American Pediatric Society. The gums were 
generally affected in infants with teeth, and were swollen and spongy 
in 24 cases in which there were no teeth. They may be normal in 
severe cases if there are no teeth, and swollen in mild ones. The 
symptoms in older children resemble those of adults. In one case 
in a child over two years of age the surgeons of a dental clinic had 
been consulted for an uncontrollable bleeding of the gums. The 



Fig. 162. 


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HOUR 369 12 369 12 369 12 369 12 369 12 369 12 36912369 12 S69 12 369 12 369 12 369 12 3 6 | 9 12 369 12 








£ •*% 


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IT 102 £ 


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5 X 


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•101 \ 


. 5Z -.* ,- 


d. V-* 5* 


S X 2 3^ 


S 5* 




1U " ~~ !»»*- 


^ >■ «t 


"^ * N A^ 


=~V ^S; — C^^- 












pulse l§SsS§§ + S§S§2BSSSi§ § §SS = n SSSS3 = SsH 5 333 3 


RESP. S S S S S|S s sssssssssis s sssss sfseus gJ gsg g ^sss s 



Temperature-curve of a case of scorbutus in an infant seven months of age. Resorp- 
tion fever. The chart shows the very high number of respirations as compared to the pulse. 
Cause of high respirations probably pain and extreme anaemia. The curve taken from 
the start of treatment. 

child had ceased to walk on account of pains in the lower extremities, 
which had been interpreted as rheumatic. In older children the gums 
are affected, and the hemorrhages take the form of petechiae and 
blotches, appearing in crops over the surface of the body as in the 
adult. They have joint-pains and malaise. 

Prognosis. — The disease in infants and children gives a very 
good prognosis if recognized and treated in time. Most cases recover. 
The fatal cases are those in institutions or elsewhere in which the 
diagnosis has not been made or in which death has been caused by 
some intercurrent affection, such as cerebral hemorrhage, diarrhoea, 
or pneumonia. In 379 cases collected by the American Pediatric 
Society the mortality was 8 per cent. 

Duration. — There is no fixed duration. Much depends on an 
early diagnosis. Even if the disease has existed months before 



INFANTILE SCORBUTUS OR SCURVY. 593 

a diagnosis is made, the patient may still recover. The great danger 
is that a hemorrhage may occur in the cerebrum or that the infant 
may contract an intercurrent affection through exhaustion. If allowed 
to continue 1 without treatment, the disease may cause exhausting intes- 
tinal hemorrhages or hemorrhage of great extent elsewhere, with 
consequent anaemia and death. 

The diagnosis of infantile scurvy presents no difficulties. The 
pains iu the extremities, the paralytic phenomena, the swelling of the 
gums, the swelling in the vicinity of the joints of the limbs or along 
the shafts of the bones, the swellings on the ribs, and the ecchyinoses 
in the skin and about the eye, are all characteristic'. The pareses of 
the upper extremity are frequently mistaken for those due to syphilis. 
The history, and the absence of syphilitic eruptions will aid in diag- 
nosis. 

The treatment of infantile* scurvy is simple and satisfactory. 
The infant is given fresh, pure milk properly modified. The milk 
should be given raw, and in summer should be kept well packed in 
ice. In addition, orange-juice and lemonade are given in the 
course of the day. An infant seven months old should have 2 
ounces of lemonade and \ ounce of orange-juice in twenty-four 
hours, given every two hours after each nursing. Some authors 
advise the giving of raw beef-juice, but it is not necessary. After 
two weeks the quantity of fruit juice should be reduced, but a small 
quantity of orange-juice should be given daily for some time. Medi- 
cines are not indicated except for the anaemia, which is best treated 
by doses of half a drop of Fowler's solution given three times daily, 
or by some easily assimilable peptonate of iron. 

Leading Authorities Referred to in Chapter X. 

••American Pediatric Society Collective Investigation of Scurvy," Trans. 

Amer. Ped. S<>c. vol. x. 

Barlow: "Cases Described as Acute Pickets," Med. and Chir. Trans., Lond., 

BSrkel: Chronische Milzschwellung, Dissert.. Miinchen, 1898. 
. W. L.: -'Case of Scorbutus," New York Med. Rec., 1892. 
Uinjen, M. : " Weiss.-blut Korperchen beim Menschen," Jahrb. f. Kinder.. 

Oheadle: "Cases of Scurvy and Rickets," Lancet, 1878. 

Ehrlich and Lazarus: u Di<- Amende,'" Nbthnagel's Spec. Path, nnd Therap., 
Bd. viii. 

Ekrlieh, P.: Histologic des Blutes, Berlin, 1891. 

Escherich^ '/'..- "Status Lymphaticus," Berlin, klin. Woch., 1896. 

.- "Osteal and Periosteal Cachexia," St. Bart. Hosp. Pep., 1881-1889. 
ler and Japha: " Beitr. zur Amende," etc., Jahrb. f. Kinderheilk., 1901. 

Oundobin : " Morph. u. Path, des Blutes," Jahrb. f. Kind., 1893. 

Hayem, <;.-. Da Sang, Paris, 1889. 

Hoch nnd Schlaringer: u rTssmatolog. Studien," Beitrg. zur Kinder., 1892. 

Henoch^ E.: " I'eber eine Eigenthum Form von Purpura," Verhandl. Berlin. 
Med. (resell.. 1874. 

Jaeobii A.: u Anatomy nnd Pathology of Tlivraus,'' Trans. Assoc. Amer. Ph vs.. 
1888. 

■ Archive- of Pediatrics, 1892. 



594 THE LYMPH-NODES AND DUCTLESS GLANDS. 

Jaksch, V.: "Ueber Leuksernie u. Leukocvtose in Kindesalter," Wien. med. 
Wochen., 1890. 

Japha, A.: " Leucocvtose," etc., Jahrb. f. Kinder., 1901. 

Koch, Wm. : " Die Blut-Erkrankheit," Deutsche Chir., Lief 12. 

Limbeck; B. B. : Grundriss klin. Path, des Blntes, 1892. 

Monti and Berggriin : Die chronische Anaemie," etc., Wien, 1892. 

Morse, J. L.: " Infantile Scorbutus," Boston Med. and Surg. Jour., 1901. 

"Chronic Enlargement of the Spleen in Infancy," Annals Gynaecol, and 

Fed., 1900. 

Northrup and Crundall : " Infantile Scurvy," New York Med. Jour., 1894. 
Northrup: "Scorbutus," New York Med. Kec , 1889 ; Archiv. of Ped., 1892. 
Osier, Wm.: "Sporadic Cretinism in America," Amer. Jour. Med., 1895. 

" Cretinism in America," Trans. Cong. Arner. Phys., 1897. 

Botch and Lladd: "Pernicious Anaemia," Trans. Amer. Ped. Soc, 1901. 
Schiff, E. : "Haematolog. Studien der Neugeborenen," Jahrb. f. Kind., 1901. 
Schodel and Nauwerck, Moller, Barlow, Krankheit., Jena, 1900. 
Schmorl: Verhandl. Versammlung Deutsch. Naturforsch., 1899. 

" Ueber Storungen des Knochenwachstums bei Barlow'schen Krank- 
heit." 

Stengel and White: "The Blood in Infancy and Childhood," Trans. Amer. Ped. 
Soc, vol. xii. 

Thomson, J. : "Sporadic Cretinism," British Medical Journal, 1898. 

" Achondroplasia," Edinburgh Medical Journal, 1893. 

"Thyroid Feeding in Cretinism," Edinburgh Medical Journal, 1894. 

Triesethau, Wm. : Die Thymus, Dissert., Halle, 1893. 

Van Arsdale, W. W. : " Cervical Adenitis," Trans. New York. Acad. Med., vol. 
viii. 

Wentworth, A. H.: " Assocation of Anaemia and Chronic Enlargement of the 
Spleen," Trans. Mass. Med. Soc, June 11, 1901. 



CHAPTER XI. 

DISEASES OF THE BOXES. 

THE BONES. 

General Facts. — In examining the joints, it should be borne in 
mind that the bones entering into the formation of the joints may 
be affected. The diaphysis may be diseased without accompanying 

involvement of the joint. 

Tuberculosis. — In all bone lesions tuberculosis should be excluded. 
In infants and children, the question as to whether the existing 
condition is tuberculosis of the bone or syphilis is constantly arising. 

Syphilis affects by predilection the long bones in the diaphysis, 
while tubercle affects the short bones, especially in the vicinity of the 
joints. In this region, also, tubercle attacks the epiphyses of the 
bone and may thus involve the joints secondarily. 

Pain in syphilitic bone lesions is very marked, acute, and with 
nocturnal exacerbations ; while the pain of tubercular bone lesions 
is obscure and indefinite, although persistent. 

The swelling in syphilis is in the form of a periostitis or an ostitis 
involving only the bone; in tuberculosis, the surrounding tissues are 
affected a> well as the bone, and abscess and fungous granulation 
result. 

Syphilis rarely suppurate-; the contrary is true of tuberculosis. 

Syphilis of the bones does not as a rule lead to cachexia ; tuber- 
culosis of the bone eventually causes cachexia and emaciation. 

There are cases in which doubt will arise as to the true nature of 
the bone affection. This is especially the case when the small bones 
of the hand are affected. 

Sudden painful swelling of the long bones occurring in corre- 
sponding hone- on both sides should awaken a suspicion of syphilis, 
even in the absence of other Bigns of syphilitic disease. A long 
bone which has been affected by syphilis will be irregularly thick- 
ened, owing to the repeated attack- of periostitis. This thickening 
IS likely to be confounded with that caused by rachitis. 

In rachitis, the bone is Less painful than in syphilis and the 
thickening \g invariably uniform and smooth. In scurvy there 
may be a thickening of the long bono due to hemorrhage in the 
periosteum. In these cases the history and also the presence of other 
signs of scorbutus, such a- hemorrhages in the skin or bleeding of 
the. gums, will aid diagnosis. 

595 



596 DISEASES OF THE BOXES. 

Craniotabes. — In locating patches of so-called craniotabes, the 
surface of the occipital and other bones of the skull is examined 
for deficiency of bone formation. The occipital bone will in rachitis 
present membranous spots more frequently than is generally sup- 
posed. The most common tumors found on the scalp are those 
due to traumatism at birth, such as cephalohsematoma, tumor of 
the scalp with depressed bone, and tumor due to syphilis. The 
cephalohsematoma is found after birth and need not be described 
here. If an infant falls on one side of the head from a height, 
a depression of the skull at once takes place. This occurs if the 
bones are soft and not yet completely ossified. The depression is 
filled with an effusion of blood and serum. A soft tumor results 
which may not project above the surface at all or only slightly so. 
Around the border of the tumor the rim of bone bordering the de- 
pression can be felt. In this respect the condition differs from the 
cephalic hematoma found after birth. In the latter, the whole 
tumor is raised from the surface, and on physical examination 
there are no evidences of depression. 

Syphilis (see Fig. 78) may cause on the surface of the frontal and 
parietal bones tumors varying from the size of a hazelnut to that 
of a walnut. They may at first be hard and subsequently soften. 
They resemble abscesses, and should be differentiated from them. 
Tuberculosis of the bones may also cause such tumors. Tuberculosis 
of the skull bones in infancy is of rarer occurrence than syphilis of 
the skull, the cases of disease of the ear being excepted. In a concrete 
case, syphilis should be assumed until it can be excluded. Abscess 
may be diagnosed if there are abscesses elsewhere in the body. This 
is the case in folliculitis abscedens of Escherich. Mistakes rarely 
occur in these cases, since all the signs of abscess are present. 



OSTEOMYELITIS. 

Osteomyelitis is an acute infectious inflammation of the struct- 
ure of the bones. It is common in infancy and childhood. Of 
50 cases below the thirteenth year collected by Blumenfeld, 50 per 
cent, were under five years of age. The sexes were equally affected. 

Etiology. — In the majority of cases the essential cause is the 
Staphylococcus pyogenes aureus. The disease may, however, be 
caused by any micro-organism with pyogenic tendencies, such as the 
Streptococcus pyogenes, the pneumococcus, and the Bacillus typhosus. 
Of 90 cases collected and reported by Lannelongue, only 10 were 
due to the streptococcus. Lannelongue and Achard were the first 
to show that osteomyelitis may be caused by streptococci, in 1890. 
Van Arsdale and I, in 1891, published 4 cases of osteomyelitis 
caused by streptococci. These occurred in newly born infants or 



OSTEOM YELITIS. 59 7 

followed scarier fever and pneumonia. The streptococcus osteo- 
myelitis i> of especial interest to the physician, as it occurs in infants 
and children under two years of age. It frequently follows infection 
of the umbilicus in the newly born infant, the exanthemata (scarlet 
fever and measles), and pneumonia. It differs from the staphylo- 
coccus variety in that the inflammation of the bone is less likely to 
involve the medullary canal, but affects the epiphysis. There is also 
involvement of the joints, with suppuration. The bacteria gain 
access to the circulation ((Jarre), and to the bones through some 
wound such as the umbilicus, through the mucous membranes, as in 
ulcerations of the mouth, through some lesions of the skin such as 
an eczema or furuncle, or through the gut. Of the 47 cases cited 
above, 17 were due to trauma and 5 followed infectious diseases. 

Symptoms. — In older children, the symptoms differ little from 
those of the adult subject. The femur and tibia are most commonly 
involved ; next the humerus, superior maxilla, inferior maxilla, ileum, 
and radius, in the order named. In some cases the onset is sudden 
and the fatal issue takes place in a few days. In others, the inva- 
sion is gradual. In older children there are the regular symptoms 
of chill, fever, and vomiting, followed by local symptoms; 

In young infants the signs of osteomyelitis are obscure. In the 
puerperal cases in newborn infants, the umbilicus may be inflamed 
for some days, after which the infant begins to cry when handled in 
the bath. One extremity is not moved and a joint may be swollen. 
Swelling of the joint may escape notice until the child is examined 
by the physician. After scarlet fever, the swelling of the joints is 
quite apparent, and also after pneumonia. In the newborn infant 
Beveral joints may be swollen. In one of my cases in an infant 
ten months old, the elbow-joint and wrist-joint were involved, 
the whole radius being the seat of osteomyelitis. Similar eases 
have been published in this country by Gibney. The frequency 
of joint-involvement i- a feature of osteomyelitis in children. Of 
50 cases of osteomyelitis published by Blumenfeld, the joints were 
involved in 30. I have seen the multiple joint-suppurations most 
frequently in newborn infants. In all cases, there are evident swell- 
ing of the tissues about the joints and fluctuation in the joint-cavity. 
The joint contain- pus. 

The diagnosis i- not difficult. It" an infant cries when it is 
handled, every .joint should be carefully examined. Osteomyelitis 
may be confounded with scorbutus. In the latter affection, the 
joint- an- painful and swollen, but do not contain fluid. In 
scorbutus there nre ecchymoses, -welling and sponginess of the 
gums, and hemorrhagic lesions underneath the skin, all of which 
will aid in diagnosis. A history of umbilical inflammation or of 
scarlet fever i- of great value. There are in congenital syphilis in 
young infants forms of inflammation about the joints which at first 



598 DISEASES OF THE BONES. 

simulate osteomyelitis. In such eases the infant should be exam- 
ined for other evidences of congenital syphilis, such as fissures and 
rhagades about the mouth and anus, mucous patches, and coppery 
discolorations of the skin. Tuberculous inflammation in the long 
bones or in the heads of the bones may present some difficulties 
of diagnosis. A study of the case and the absence of a history of 
acute trouble \vill solve the difficulty. 

The prognosis of acute osteomyelitis in newly born infants is 
bad. The majority of cases are fatal owing to the formation of 
multiple foci of suppuration. The prognosis is also bad in infants 
under one year of age. The mortality of all cases under the fifth 
year is 56 per cent. In older children it is 20 per cent. 

The treatment of acute infectious osteomyelitis is surgical. 



OTITIS IN INFANCY AND CHILDHOOD. 

Frequency. — Otitis media, catarrhal or purulent, is a very 
common disease of infancy and childhood. It is, as a rule, a sec- 
ondary affection, but may in rare cases occur as a primary disease. 
Parrot first called attention to the frequency of otitis as a complica- 
tion of bronchopneumonia. Netter made the first bacteriological 
examinations of the discharges from the ear. The subjects were 20 
children whose ages ranged from nine days to two years. Kossel, 
Rasch, and Ponfick have investigated the frequency and nature of 
this affection in children. The results of their work show striking 
uniformity. Fully 85 per cent, of infants and children, examined 
post mortem, were found to have diseased ears. Most of the infants, 
especially in the material examined by Ponfick, had died of gastro- 
enteritis, acute or chronic. Some had suffered from gastro-enteritis, 
pneumonia, or congenital syphilis. 

The etiology of acute catarrhal, acute suppurative otitis media 
and of acute suppurative mastoiditis is much the same. The naso- 
pharynx and the Eustachian tube are normally the habitat of various 
forms of bacteria. This is especially the case in infants and chil- 
dren who have enlarged tonsils and adenoid growths. A reduction 
of the vitality of the individual or any acute disease favors inva- 
sion of the ear by bacilli entering through the Eustachian tube. 
Thus the exanthemata, especially scarlet fever and measles, furnish 
a large quota of cases. Diphtheria, typhoid fever, typhus fever, 
varicella, influenza, gastro-enteritis, tonsillitis, and simple angina, 
also cause a large number of cases of otitis. Pertussis, cerebrospinal 
meningitis, and pneumonia are complicated by this disease. Sea- 
bathing, exposure to cold, and nasal douching favor its onset. 

Bacteriology. — The bacteria found by different observers in the 
otitic discharges and in the cavities of the ear include the Staphy- 



OTITIS IN INFANCY A XI) CHILDHOOD. 599 

locoecus pyogenes aureus, citreus, and albus, the Streptococcus pyo- 
genes, the pneumococcus of Friinkel, the influenza bacillus and 
pseudo-influenza bacillus, the Bacillus foetidus, and the Bacillus pyo- 
cyaneus (Netter, Kossel, Ponfick). The streptococci and influenza 
bacilli cause an especially severe inflammation, the pneumococcus 
a milder form. The diphtheria bacillus also causes otitis. 

Morbid Anatomy. — In both forms of otitis and also in mas- 
toid disease the tympanic membrane is injected and the vessels at 
its border are increased in size. The vessels of the hammer are 
injected. The epidermis of the tympanic membrane may be intact. 
The tympanic cavity may be filled with cellular elements. There 
may be a serous, mucous, purulent, or mucopurulent exudate. The 
mucous membrane of the tympanic cavity may be intact but injected, 
or may show otos- defects. If the bony structures are involved, there 
will be necrosis of bone, especially of the tegmen tympani. There may 
be perforation of this structure or of the point of the mastoid process. 
The dura mater or >inuses of the dura may, in progressive mastoid, 
be inflamed. There may be cerebral abscess. If the pus does not 
escape by way of the Eustachian tube, it may perforate the tym- 
panum. The exudate which fills the tympanic cavity contains epi- 
thelial cells, leucocytes, and blood-cells. 

Otitis Media Catarrhalis. — Acute catarrhal otitis is, in a vast 
number of cases, simply a forerunner of otitis media purulenta or of 
an acute suppurative otitis. It will be convenient for the practitioner 
to consider these affections together. 

Thev are more common among infants and children than among 
adults, and may occur at the earliest period of infancy. They occur 
most frequently in the spring and summer. 

The causation has been considered under the etiology, and is 
the same in both affection.-. 

Symptomatology. — In young infants and in children under two 
years of age, the symptoms are frequently masked by those of the 
primary disease. In many cases, the otitis gives no special warn- 
ing of it- presence. Perforation of the drum and a purulent dis- 
charge are the first intimation of the condition. This is especially 
the case in otitis in young nurslings who have suffered from acute 
tonsillitis or pneumonia, but these are not the cases which the practi- 
tioner i- called upon to diagnose. In another se< of cases, especially 
in those in which otitis i> coincident with gastro-intestinal dis- 
orders of a chronic type, tending to atrophy, Eleermann and Ponfick 
have Bhown that during life it give- no objective symptoms although 
OH Otoscopic examination the tympanic cavity i< found to be filled 
with pus. In cases which follow the milder types of influenza or 
angina, there may be a most puzzling set of symptoms which can 
only be referred to the car. In these cases the physician find-, two 
or three days after the on-et of tonsillitis or influenza, that the 



600 



DISEASES OF THE BONES. 



temperature does not drop to the normal ; it may mount to 104° F. 
(40° C.) toward evening, and in the morning may drop to or within 
a degree of the normal. While the temperature is low the infant 
takes its food and plays. When it rises the infant becomes fretful, 
or stupid, or sleeps most of the time. There is no indication of 
pain. In some cases the infants perspire freely at the falling of the 
temperature. These simulate in many respects cases of malaria or 
of meningitis of the tuberculous type, except that the tempera- 
ture rises higher than in the latter disease (Fig. 163). Local facial 
pareses may complete the resemblance to meningitis. The intermittent 
or recurrent curve of temperature may continue for a week or ten days. 
Only the careful exclusion of disease of other organs, and especially 
of the lungs and of the heart, will lead the physician to suspect 
disease of the ear. In nursing infants the bowels will be abnormal 
and the movements greenish, containing white curds. The tempera- 
ture is, however, much higher than in any diarrhoea, and is more 

Fig. 163. 



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Otitis media purulenta in a child eighteen months of age. Symptoms and curve simulating 
closely a meningitis of the basal type. 



persistent and regular in its daily- fluctuations. In cases of broncho- 
pneumonia complicated with otitis, previous to the spontaneous per- 
foration of the drum the temperature will have shown more decided 
fluctuations than would occur at a late stage of the primary disease. 
However, in pneumonia there are few or no objective signs of the 
affection. Older children may have certain definite symptoms such 
as dull headache and pain in the ear, which, if sharp and sting- 
ing, will cause them to start in sleep, or to awake and cry out or 
put the hand to the ear. This last sign, so often mentioned in the 
text-books, I have seldom seen. There may be delirium and the 
fever may be quite high. Children, who can talk, complain of pain 
at night. There may be rushing, singing, or buzzing noises in the 
ear. Very characteristic is the starting of infants during sleep. 
Older children are out of sorts, and angry on awakening. 

Course. — Spontaneous perforation in a number of cases occurs 
in a few hours or a few days after the onset of the disease. As a 
rule, however, pain continues with fever until artificial paracentesis 
of the drum is practised. After spontaneous rupture of the tympa- 



THE MASTOID EEGIOX. 601 

num, or paracentesis, the discharge may continue, being in some 
cases scions or serosanguinolent, and later becoming purulent. The 
purulent discharge may be profuse and the disease may advance into 
the mastoid or labyrinth. This frequently occurs in eases of the ex- 
anthemata or in pneumonia or influenza. In severe eases, the 
discharge may continue and become chronic, resulting in destruction 
of the structures of the car. Complications may intervene, such as 
facial erysipelas, meningitis, cerebral abscess, thrombosis of the 
cerebral sinuses, and finally in suppurative cases pyaemia may inter- 
vene. On the other hand, after spontaneous rupture or paracentesis 
of one or both drums, the serous or purulent discharge may gradually 
cease and the ears be restored without any defect of hearing. In 
many cases incision of the drum in the very early stages of the dis- 
ease is not followed by the discharge of pus ; the symptoms cease, 
and the patient recovers. In other cases, there is no rupture of the 
tympanum, although the tympanic cavity is filled witli exudate, 
which discharges through the Eustachian tube. The pus may be 
swallowed and cause violent diarrhoea or pneumonia. In the cases 
of marasmus witli otitis described by Heerman, the pus is believed 
to have found its way from the middle ear through the tube to the 
nasopharynx. 

The diagnosis is first made from the rational symptoms. In my 
experience, the temperature-curve is a very useful guide in infants 
who give no evidence of pain. Otoscopic examination is the only 
positive means of making a diagnosis. There is congestion of the 
tympanum above ShrapnelFs membrane and the long handle of the 
malleus. In the catarrhal cases the tympanum is red and angry 
or ha- a grayish lustre. The handle appears as a red or yellowish- 
white point. In some cases there are vesicles and interlamellar 
abscess. The exudate may cause bulging of ShrapnebVs mem- 
brane or of the posterior-superior quadrant. Congestion remains 
long after resolution. In the suppurative cases the epithelium 
of the tympanic membrane may peel off. The tympanum is dull 
and lustreless. The auditory canal may be swollen. Perforation 
occurs, chiefly in the posterior-inferior quadrant. There may 
be pulsation of the membrane as well as bulging. The lymph- 
Dodes beneath the ear may enlarge and thai region may be very 
sensitive. 

The prognosis in ordinary cases is good. In cases following the 
exanthemata it i< grave, on account of the possibility of complica- 
tions and of ultimate loss of hearing. 

THE MASTOID REGION. 

General Facts. — The mastoid region is important on account 
of the frequency of mastoid disease in infancy and childhood. In 



602 DISEASES OF THE BONES. 

early life there is pneumatic tissue, but no mastoid cells are found. 
The mastoid process contains one large cell (Symington). The exter- 
nal wall is less thick and compact than in the adult. The petro- 
squamous suture is patent. The petrosquamous sinus is persistent in 
some cases, passes through a foramen on the inside of the skull, and 
appears externally behind the glenoid fossa and tympanic ring. 
Thus infectious material may easily be conveyed internally. In 
infants and children pus finds its way externally more readily 
through the open fissura mastoideo-squamosa. 

Etiology. — Inflammation of the mastoid is rarely primary. The 
mastoid may at the outset be inflamed when there has been no ante- 
cedent otitis. As a rule, however, inflammation of the mastoid is 
secondary to acute or chronic otitis. The causation is identical with 
that of acute or chronic otitis. 

Of 39 cases of mastoid disease under eight years of age, collected 
by Knapp, 7 occurred in the first year, and 9 in the second. The 
greatest frequency is therefore after the second year. It may occur 
as early as the second month. I have had a case in an infant three 
months of age. The anatomical conditions favor the occurrence of 
mastoid disease in infancy and childhood. The Eustachian tube is 
short and of large calibre ; infectious material from the nasopharynx 
can easily gain access to the ear. 

Symptoms. — Clinically, mastoid disease in infancy and childhood 
manifests itself by rational symptoms and physical signs. There 
may be extensive mastoid disease without any external physical 
signs. In one of my cases of otitis, which was observed from the 
outset, extensive mastoid disease in a child of three years of age did 
not give any external signs. The clinical symptoms are character- 
istic. The drum may have been perforated after otitis, or paracen- 
tesis may have been performed. After perforation, the temperature 
present during the preceding otitis drops to the normal. The patient 
is able to be up and about. The ear discharges freely. After two 
or three weeks there is a sudden or gradual rise of temperature, 
which may be slight or may reach 103° or 105° F. (39.4° to 40.5° 
C). There is restlessness at night. On inspection, the ear may not 
show anything abnormal. The temperature, however, continues to 
be remittent for several days. On otoscopic examination, there is 
found to be swelling of the roof of the auditory canal or of the floor 
of the attic. In other cases, after a very early and timely paracentesis 
of the drum, the patient does not do well. The child is restless at 
night, at intervals irritable and then playful, and starts from sleep 
(Fig. 164). The temperature fluctuates daily from 100.8° to 102° 
F. (38.8° C). On some days it may be normal or subnormal. The 
ear discharges for days, but a slight temperature continues. If the 
patient is an infant or a young child, it may be very difficult to ascer- 
tain whether pain is present on pressure backward over the region 



THE MASTOID REGIOX. 



603 



of the antrum behind the ear. There is in early eases do swelling 

or redness behind and above the auricle. As was stated above, 
there may be extensive and advanced mastoid disease without exter- 
nal redness or swelling. In snch cases the lymph-nodes behind the 
ear and at the angle of the jaw maybe swollen and painful. Young 
children and infants do not complain of pain. It is only in older 
children that it can be noted. 

Mastoid disease which follows the exanthemata, especially scarlet 
fever or measles, or occur- late in typhoid, shows certain charac- 
teristic clinical features. During the tifth or sixth week of scarlet 
fever the car- may discharge profusely. There is a daily rise of tem- 
perature in the afternoon, which is slight in some cases. The 
patients play in the early portion of the day, but in the afternoon 
appear listless, and have a slight frontal headache. As days pass, 
the children become stupid tin ring the afternoon rise (sepsis). 



























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Otitis media in a female child, three years of acre. Observed from the onset. Early 
paracentesis, fall of temperature, then rise again. Subsequent mastoid involvement neces- 
sitating operation. 



In many cases of scarlet fever, as may be seen by referring to 
Figs. 30 and 31, otitis is a complication. The temperature does not 
fall to the normal, as it should, after the fading of the eruption. 
There is slight aural pain at night, which is sometimes sufficiently 
severe t<> deprive the patient of sleep. In other cases the tem- 
perature dmp- to the normal and suddenly rises in the second 
week. In both these sets of cases there is an otitis which may 
develop into mastoid disease, or in which mastoid disease may have 
been present from the outset. 

Korner calls attention to the feet that in late typhoid fever, chills, 
with rises of temperature, are, with other signs, indicative of serious 
mastoid disease. 

Physical Signs. — Pain is a physical sign of mastoid disease 
in children. In most cases it cannot be elicited by the mosl skilful 
manipulation. In others it is impossible to come to a definite con- 
flu-inn. Id older children pain may be elicited by pressing the mas- 
toid bone in a backward direction, care being taken not to press on 



604 



DISEASES OF THE BONES. 



the auricle. The pressure should be firm and continuous. Pain in 
the tip of the mastoid is not of value unless there has been a per- 
foration and phlegmon at that point (Dench). 

Otoscopic Examination. — There is a shortening of the external 
canal in its posterior and upper aspect (Dench). The upper posterior 
wall sinks. There is bulging of the upper portion of the tympanum. 

Tumefaction posteriorly and above the ear occurs in infants only 
in neglected cases. According to Dench, in these cases the pus 
escapes from the antrum through the aditus ad antrum into the tym- 
panic vault. It then finds its way through the Rivinian fissure 
along the upper wall of the canal to the external surface of the mas- 
toid. In children cases in which this swelling appears are less 
serious than adult cases. The swelling also appears much earlier in 
infants and children. 

Fig. 165. 




Mastoid disease in a child eighteen months of age. Swelling behind the ear over the mastoid. 
The ear is displaced away from the scalp. 



Diagnosis. — The life of the patient often depends upon the early 
recognition of mastoid disease. The diagnosis in infancy and child- 
hood should not only be made early, but should be made chiefly from 
the clinical symptoms of temperature, which will in its fluctuations 
show a septic curve. The history of the case is of service. Pres- 
ence of pain is of no value in infants and young children. The 
daily otoscopic examination of the discharging ear will give positive 
evidence of mastoid disease. The signs detailed in the paragraph 
on symptoms are of great importance. A profuse discharge does not 
preclude mastoid disease. Facial paralysis is of no value. I have 
seen it in cases in which mastoid disease was on operation found to 



THE MASTOID REGION. 605 

be absent. Tumefaction is seen only in late eases. Redness is 
sometimes apparent before the appearance of swelling behind the ear. 

Course. — If a ease Is neglected, pus from the mastoid may force 
its way through the tympanic roof and cause cerebral abscess or 
meningitis. It may destroy the plate (lamina vitrea) of the sigmoid 
sinus and cause thrombosis, may find its way through the tip of the 
mastoid along the border of the sternomastoid, and cause phlegmon, 
or may force itself through the sutura mastoideo-squamosa, causing 
-welling behind the auricle. 

Treatment. — Prophylaxis. — Children can be taught to tolerate 
the therapeutic measures which, if catarrhal inflammation of the 
fauces is present, as in the exanthemata, will cleanse the parts. Tims 
in scarlet fever, an intelligent child will readily allow the throat to 
be sprayed with normal saline solution. Swabbing the throat or 
applying any drug locally is impracticable in children. 

If the pain is excessive a mild opiate, such as paregoric, is 
administered. In young infants the severity of pain cannot be 
estimated. In older children dry heat applied externally to the 
ear by means of a water cushion relieves the pain. Some authors 
advise the application of leeches behind the ear, or the instillation 
of water at 110° F. (43.3° C.) into the canal with a dropper. 
Inflation of the ear in the early stages of otitis media has been 
advocated and condemned. Suction by means of a catheter intro- 
duced into the Eustachian tube is also practised. If the pain and 
fever are not relieved by these measures, incision of the drum 
Is resorted to. Whether the otitis is catarrhal or purulent, it is 
best performed early, since damage to the ear may thus be avoided. 
The method of performing paracentesis of the drum is best learnt 
fr«»m special text-books on the subject. Duel advises enlargement 
of the opening in cases in which spontaneous rupture of the drum 
has taken place. Drainage by the introduction of sterilized absorb- 
ent gauze into the canal is superior to syringing. If this is not pos- 
sible, syringing with 1 : 5000 bichloride is useful. 

The indication- for the performance of mastoid operation are 
protracted otitis with profuse otorrhcea, there being no tendency to 
resolution, acute otitis in which there is a tendency to resorption 
;iinl in which paracentesis has not established drainage, also muco- 
purulent otitis maintained by mastoid involvement, otitis with 
symptoms pointing to meningeal complications, and finally otitis with 
complicating stenosis of the externa] canal, preventing drainage. 

Leading Authorities Referred to in Chaptek XI. 

Babes, .i. ; Bacteriol. [Intersach. fiber septische Proaespeim Kindesalter, Leipzig, 

BbumenM&f F. . Acute Osteomyelitis ira Kindesalter, Dissert., Marburg, 1900. 
Oohn, ¥.: " Indications for Perforating the Mastoid," N. V. Med. Jour., 1896. 



606 DISEASES OF THE BONES. 

Courmount et Jaboulay : lt Sur les microb de l'osteomy elite," Comp. rend hebdom. 
des Sciences de la Soc. Biol., 1890, No. 18. 

Bench: "Mastoiditis," Journal American Medical Association, 1901. 

" Mastoid Complications of the Exanthemata," Pediatrics, 1899. 

Duel, A. B. : "Acute Otitis Media and Mastoiditis in Scarlet Fever," Med. 
Review of Reviews, Michigan, 1901. 

Gaessler, B. : Mittelohres bei Scarlatina, Thesis, Wiesbaden, 1900. 

Hermann, G. : Otitis Media in friiheren Kindesalter, Halle, 1898. 

Korner, Otto : Die Otitischen Erkrankungen, 1896. 

Lannelongue et Achard : " Des Osteomy elite a Streptococque, La semaine Med., 
1890 ; Academy of Sciences, 1890. 

Botch, T. M.: ll Multiple Osteomyelitis in an Infant," Trans. Amer. Ped. Soc, 
vol. xi. 

Van Arsdale, W. W., and Koplik, H. : "Streptococcus Osteomyelitis," Trans. 
New York Academy of Medicine, vol. viii. 



CHAPTER XII. 

DISEASES OF THE LIVER. 

Anatomical. — The weight of the liver in infants and children 
is from one-twentieth to one-thirtieth of the hodv weight ; in the 
adult it is one-fortieth. 

Examination. — The liver is examined with the patient in the 
recumbent or semirecumbent posture. The physician may palpate 
for the liver or mark out the organ more accurately by percussion. 
In marking out the organ, the upper limit, the lower edge, and the 
area of superficial dnlness are determined. Perfect accuracy by 
deep percussion is not feasible, because in order to obtain absolute 
dnlness some force must be used, and vibratory echoes of other 
neighboring organs — the lungs and intestines — are thus caused. In 
all cases it is well to determine the upper limit of dulness at a 
point where the liver comes in contact with the chest-wall. 

The lower border of the liver is determined by palpation and 
percussion. The lower border projects normally in infants and 
children below the border of the ribs. In the right mammillary 
line this projection may vary from 1 to 2.5 cm. At the xiphoid 
appendix the liver may project to the extent of 2 to 6 cm. and still 
be within the normal limits. These conditions may exist up to the 
tenth year. The exact age at which the liver assumes the adult 
dimensions lias not been determined. In some adults, however, 
the projection below the border of the ribs is the same as in chil- 
dren. Since the size <>f the liver varies, caution should be exercised 
in pronouncing the organ enlarged. The gut, ascites, and tympan- 
itic distention may obscure the lower limit of the liver both to pal- 
pation and percussion. 

Palpation. — By palpation, the location of the lower border of the 
live]' may be determined, and whether it is rounded or sharp, also, 
if the liver be enlarged, the character of the projecting portion, 
whether smooth or uneven. In infant- and children the region of 
the gall-bladder is palpated, but it is difficult to determine in these 
subjects whether this organ ifi enlarged or absent. Henoch and 

Murchison have recorded fatal cases of increasing and persistent 
icterus in which there was congenital absence of the gall-bladder. 

Percussion. — Percussion should be performed in the mid-line 
from the base of the xiphoid cartilage downward, in the right 
mammillary line from above downward, and sometimes in the mid- 
007 



608 



DISEASES OF THE LIVER. 



axillary line. In order to determine accurately the superficial dul- 
ness, the whole extent of the dulness should be measured. This is 
rarely necessary except in investigations for scientific purposes. Iu 
cases of effusion into the pleural cavity, the upper limit of dulness 
is continuous with the dulness or flatness of the fluid. The displace- 
ment below the border of the ribs only can then be determined. 
In rare cases of subphrenic abscess there is an extension of the 
upper limit of dulness into the limits of the chest cavity, and 

Fig. 166. 




Method of palpating the projection of the liver below the ribs. 

displacement of the lower border of the liver downward. Steffen 
gives the following measurements of the superficial liver dulness in 
the median and mammillary lines : 

Midline. Mammillary lir;e. 

At birth 3.5 cm. 2 cm. 

At one month 5 " 5 " 

At six months 4.5 " 4.5 " 

At one year 4.5 " 4 " 

At two years 5.2 " 5 " 

At five years 5 " 6.5 " 

At ten years 5 " 6 " 

These measurements also vary greatly, especially in infants under 
one year of age. 

The following tumors and conditions simulate enlargement or 
disease of the liver : phantom tumor ; circumscribed empyema, or 
pleuritic effusion ; subphrenic abscess ; circumscribed peritoneal 
effusion between the liver and diaphragm ; tumors or cysts of the 
right kidney. 

Phantom tumor is described by Murchison. It is a soft or 
hard epigastric tumor, which may project downward as far as the 
umbilicus. Whether it is dull with a tympanitic note, or tympanitic, 
depends on the amount of muscular contraction. There is no fluc- 
tuation or flatness. The tumor is present when the patient is stand- 



JAUNDICE. 609 

ing or in the recumbent position. It disappears under anaesthesia. 
A tumor of this kind should not be punctured until it has been 
observed under anaesthesia, since there is danger of puncturing the 
intestine and causing peritonitis. 

Empyema. — In simple or encapsulated empyema on the right 
side, the liver is displaced downward. The upper dulness extends 
into the pleural cavity ; the lower part of the thorax may enlarge 
to such an extent as to press the ribs apart and cause fluctuation 
between them. There will be dulness or flatness in front or behind 
over the lower part of the pleural space, and perhaps disappearance 
of the respiratory murmur. It should not be forgotten that there is 
always a possibility of the presence of subphrenic abscess, or of 
abscess in the upper part or on the surface of the liver, bulging into 
the pleural cavity. In that ease there will not only be bulging of the 
lower ribs, but also a continuation of dulness for a variable distance 
upward. The liver may be enlarged downward or not at all. If 
the tumor is beneath the diaphragm and displaces the liver down- 
ward, the respiratory murmur may be heard to the normal, or almost 
normal, limit, and yet dulness due to the upward projection of the 
tumor may be present. 

KlDNEY tumor may extend from behind, beneath the liver, and 
simulate liver tumor. In such cases, the lumbar flatness extending 
below the border of the ribs will be a guide. 

Enlargements of the Liver. — Enlargements of the liver 
in infancy and childhood present much the same physical signs as in 
the adult, but there are some states which are peculiar to early life. 

A.V.EMIA INFANTUM PSEUDOLEUK^MICA OF VOX JAKSCH 

causes great enlargement of the liver and spleen. The lower edge 
of the liver is rounded ; the lymph-nodes are enlarged, and the 
blood presents certain features characteristic of this anaemia. 

SIMPLE rachitis causes slight or marked enlargement of the 
liver, a- well as real enlargement of the spleen. In some cases, the 
liver is not really enlarged, but may be displaced downward by the 
deformity of the thorax. Simple icterus usually causes enlargement 
of the liver, which retrogrades after a few weeks. 

Congenital syphilis may cause slight enlargement of the 

liver which, up to the end of the second year, is present without 
icterus. The liver is enlarged in cirrhosis, abscess, and fatty degen- 
eration of the organ. It is greatly enlarged in acute and chronic 
leukaemia. 

JAUNDICE. 

Uarrkal Teterm; C 1 ni<irr)t<il Jaundice; Infection* Icterus.) 

Simple jaundice i> ;i common disease of infancy and childhood. 
In its simplest form, it was formerly believed to be due to an 
3S 



(HO DISEASES OF THE LIVER. 

obstruction of the common bile-duct with mucus. In recent years, 
the French clinicians have described a form of jaundice which they 
regarded as infectious. The first cases of the kind were published 
in 1881 by Weiss, Chauffard, and Landouzy, in France, and by 
Weil, in Germany. There is at present a tendency to regard all 
cases of jaundice in infants and children, not due to mechanical 
obstruction of the duct or disease of the liver, as infectious (Botkin, 
Hennig, Barthez, Henoch, and others). Thus simple icterus would 
be regarded as a mild form of infectious icterus. This view has 
recently been elaborated by Kissel. The theory, that errors of diet 
cause a catarrh of the gut, extending into the duct and thus 
obstructing it, finds little support. On the other hand, the theory 
of the infectious nature of even the mildest cases of jaundice is sup- 
ported by the fact that these cases occur in groups and epidemics. 

Morbid Anatomy. — In cases of fatal icterus, there are found 
atrophy and fatty degeneration of the liver cells. The interstitial 
tissue around the portal vein is infiltrated with small round cells. 
There is parenchymatous degeneration of the kidney. The whole 
picture resembles that of acute yellow atrophy. The mild cases of 
icterus have not yet been studied. 

Bacteriology. — The bacteriology of the severer form remains to 
be studied. In one case Jager found a bacillus of the proteus 
group in the urine. 

Occurrence. — The disease may appear at any period of infancy 
and childhood. It is most common between the second and fifth 
years. 

At present, all primary forms of jaundice may be clinically clas- 
sified as follows : The very mild forms (catarrhal icterus); the severer 
forms ; the fatal forms. It is highly probable that all are infectious 
in origin. The secondary forms of jaundice are not considered in this 
section. 

Symptoms. — In the mildest forms there are no symptoms at the 
onset. In some mild cases there are vomiting and fetor of the breath, 
and the tongue is coated. The skin assumes a saffron hue and the 
conjunctiva? are distinctly yellow. The appetite is capricious ; the 
urine is brownish and contains bile-pigment. The movements are 
like clay, and may have a bad odor. There is pruritus of the sur- 
face. The child may be somewhat depressed. In the very mild 
forms there is no febrile movement. In the majority of cases, there 
is rapidity of pulse and, in some cases, irregularity. In the severer 
forms the symptoms are more marked. The vomiting recurs at 
intervals, the intensity of the jaundice is much the same as in the 
mild forms, and the temperature may in the course of the disease be 
raised a degree or more. The attack may be ushered in by a chill. 
There is some prostration and, in a few cases, diarrhoea. The fatal 
cases, which were first described by Weiss and the French school, 



ClREHOSfS OF THE LIVER. 611 

are severer forms of infection. The symptoms of cholsemia are 
much more marked. There are delirium, unconsciousness, and 
cerebral symptoms. The pulse is greatly increased and the respira- 
tions are irregular. The patients die in an asthenic state. 

The Liver is enlarged in even the mildest farms. In a recent 
scries of '20 cases of mild icterus, I found the liver enlarged from 
four to seven centimetres below the border of the ribs, in the mam- 
millary line. The spleen was enlarged in most cases. The fact that 
in the mildest forms there is enlargement of the spleen lends support 
to the infectious theory of the disease. In the majority of my cases, 
the liver remained enlarged long after the icterus had disappeared. 
Kissel also found this to be the case. In some cases, three months 
elapsed before the liver returned to the normal limits. 

Duration. — The disease, even in the mild form, lasts from two to 
three weeks. The fatal forms may run their course much more rapidly. 

The treatment of icterus is very simple. An initial dose of 
calomel is given and the bowels arc well evacuated. The patient is 
put on a milk diet, and is given a daily enema of water at a tem- 
perature of 85° F. (2i>.4° C). On every second day a small dose of 
calomel, grain I (0.03), is given to aid the enemata. Fresh air and 
daily alkaline baths are beneficial. Alkaline baths are made by 
adding a few tablespoonfuls of sodium carbonate and an equal quantity 
of salt to the water. 



CIRRHOSIS OF THE LIVER. 

Cirrhosis of the liver is rare in infancy and childhood. Todten 
recently collected 15 cases. It has been observed to occur in early 
infancy (Freund, Lotzc), and also in early childhood. Many eases 
which are undoubtedly cases of syphilis of the liver have found 
their way into the literature as cases of cirrhosis. The disease is 
more frequent in males. 

Morbid Anatomy. — The hypertrophic is the most common form 
of cirrhosis in infants and children. Henoch has published '1 cases 
of the atrophic variety. The 'morbid anatomy of the affection is 
the same as in the adult. 

The symptoms, which are the same as in the adult, include 
enlargement of the liver and spleen, icterus, and ascites. The 
icterus i-, as in the adult, constant.' 

Etiology. — Demme ha- published '2 cases in children addicted to 
the use of alcohol. Wilke, Gerhardt, and Murchison publish similar 

The influence of heart disease and the infectious diseases, 

such a- scarlet fever ami measles, in causing cirrhosis of the liver 
i- not a- yet understood. Cirrhosis of the liver occur- in forms of 
peritoneal tuberculosis and in Byphilis. 



612 DISEASES OF THE LIVER. 

ABSCESS OF THE LIVER. 

(Suppurative Hepatitis.) 

This disease occurs in the newly born as a form of sepsis. Other- 
wise, its etiology in infancy and childhood is identical with that in 
the adult. It may follow a traumatism or complicate appendicitis 
(septic), may occur in peritonitis with pyelophlebitis, or may follow 
the infectious diseases. In the literature rare cases are described, in 
which Ascarides lumbricoides have caused abscess of the liver in 
children, by migrating into the gall-bladder through the common 
duct. 

Symptoms of abscess of the liver in children are the same as in 
the adult. 

FATTY DEGENERATION OF THE LIVER. 

Fatty degeneration of the liver with or without enlargement of 
the organ occurs in forms of subacute and chronic constitutional 
dyscrasia. I have seen this disease in infants who died with tuber- 
culosis, chronic or subacute intestinal diarrhoea, rachitis, Henoch's 
purpura, or acute leukaemia. . I have also seen it in cases of phos- 
phorus poisoning. The symptoms and signs do not differ from 
those seen in the adult. The diagnosis can hardly be made during 
life. 

SYPHILIS OF THE LIVER. 

Enlargement of the liver is common in syphilis in infants and 
children. The spleen may also be enlarged. There may be icterus. 
There may be other symptoms of syphilis, but none which can be 
traced to enlargement of the liver. 

There are four histological forms of this variety of hepatic en- 
largement : 

(a) The form in which gummata are found in the liver. This is 
rare. I have met a case in an infant sixteen months of age, in whicli 
there were gummata of the cranial and the long bones. 

(b) The diffusely cirrhotic liver. In this form the connective 
tissue is quite evenly distributed throughout the tissue of the liver. 
In the lobulated liver, the connective tissue divides the organ into 
sections. I have seen a case in a girl eight years of age. 

(c) In so-called miliary syphilis of the liver, the organ is strewn 
with miliary collections of round cells closely resembling miliary 
tubercle. The nodules are situated in the interstitial connective 
tissue. They rapidly undergo fatty degeneration. 



ACUTE YELLOW ATROPHY OF THE LIVER. 613 

ACUTE YELLOW ATROPHY OF THE LIVER. 

This disease is extremely rare in infancy and childhood. Lanz 
published a ease in a boy tour years of age. In that there was no 
splenic tumor or hemorrhages, it differed from the picture in adult 

cases. The cases in the literature are as follows : Pollitzer, infant, 
one month of agej Senator, infant, eight months; Mann, infant, 
ten months ; Greves, infant, twenty months ; Widerhofer, child, one 
and three-fourths years ; Kehn, child, two and one-half years ; 
Loselmer, child, three and one-half years ; Mettenhemier, child, four 
year- ; West, child, six years ; Merkel, child, six and one-half years ; 
Rosenheim, child, ten years ; Steiner, child, ten years ; Folwarczny, 
child, fourteen year-. 

I have seen only one case of atrophic liver. The patient, a boy 
of eleven years of age, with very small kidneys, had nephritis which 
had appeared six years after an attack of scarlet fever. The liver 
dulness became gradually smaller from the time of admission to the 
hospital until death. At autopsy, the liver was found to have one- 
half the normal weight and to be the seat of marked parenchymatous 
degeneration. 

Leaping Authorities Referred to in Chapter XII. 

Demme : EinHu>> de> Alcohols, etc.. Stuttgart, 1891. 

Epstein, .1. : "Gelbsucht bei neugeborenen Kindern," Yolkmann's Vortr., 180. 
Edwards, W, A.: •' Cirrhosis of the Liver," Archives of Pediatrics, 1890. 
Folger } C. : " Hypertrophische Leber Cirrhose." etc., Jahrb. f. Kinder., October, 
1900. 

Jaeger: "Weil's Disease," Zeitechr. f. Hygiene, 1*92. 

Libmnn, E. : " Wei]"- Disease," Philadelphia Medical .Journal. 1899. 

Law: " A<\ gelber Leberatrophie," Wien. klin. "Wochen., 1896. 

Neumaniij H. : " Gewohnliche Gelbracht," Deutsche med. Wochen., 1899. 

Schletmnger, E . . " Leber Carcinom." Jahrb. f. Kinderheilk., March. 1902. 

Todten, If.: Leber Cirrhose im Kindesalter, Miinchen, 1892. 

Weil: Deatsches Arch. f. klin. Med., Bd. xxxix. 



CHAPTER XIII. 

DISEASES OF THE KIDNEYS. 

The weight of the kidneys is T ^ 7 of the body weight in the in- 
fant and 2~j o" m ^ ne ac hilt. 

It is not, as a rule, possible to palpate the normal kidney in the 
infant or child. I have, however, seen in young infants exceptional 
cases in which the kidneys were situated very low down and could 
be easily palpated through the abdomen. I have found floating kid- 
neys in infants and older children, but not so frequently as other 
observers. Comby in 1898 reported 18 cases, of ages ranging 
from one month to ten years of age. Steiner, Stewart, and Abt have 
also reported a number of cases. I believe that the displaced and fixed 
kidney is congenital. As the child grows and the parts are stretched, 
the attachments of the kidneys, congenitally low, become more 
relaxed. This would account for a number of cases. Jacobi be- 
lieves that floating kidney in children is a congenital anomaly. 

Sixteen of Comby's cases occurred in girls. A displaced, fixed 
kidney in infants causes • no symptoms. In cases of movable kidney 
or floating kidney the main symptom is pain, either epigastric or 
radiating from the iliac region. In a girl of eight years with float- 
ing kidney, there was no difficulty in palpating the enlarged movable 
kidney below the liver. There were attacks of acute colicky epigastric 
pain, which occurred independently of the ingestion of food. The 
child was nervous and hysterical. 



THE URINE. 

The urine, during the first ten days of life, is a limpid, clear, 
colorless fluid, containing sometimes epithelial cells of the bladder 
and urethra, and sometimes urates. If there is jaundice, it may 
contain biliary pigment. It has rarely a resinous odor, as in the 
adult. 

The specific gravity during the first three days is 1010. On the 
tenth day it drops to 1002. It frequently happens that the newly 
born infant does not pass urine on the first or the second day. From 
the second to the tenth day it may urinate two or three times in 
twenty-four hours. Ruge and Robin have found that at the third 
month the infant urinates ten or eleven times in twenty-four hours, 

614 



CYCLIC ALBUMINURIA. 615 

passing 400 to 500 grammes in that time ; at five months, 400 to 
500 grammes daily ; from two to three years, 500 to 600 grammes ; 
from three to five years, 750 grammes ; and from the seventh to the 
tenth year, 1200 grammes (Parrot and Robin). 

The following tables are compiled from the results of Parrot, 
Robin, Camerer, and Schabanowa : 

Specific Amount of urine in Urea in twenty- 
gravity, twenty-four hours four hours. 

First dav 1010 15.0 0.10 

Second " " 30.0 0.14 

Third " - 60.0 0.26 

Fourth " 100.0 0.21 

Fifth to tenth day 1002 152-200 0.27-0.47 

Thirtieth to one hundred and 

fiftieth day 350 0.94 

Second year 101 -J <'.7"> 9.87 

Third to fifth year 1010-12 000-1200 13.9 

Sixth year 1012 1295 14.7.-10.4 

Tenth' " 1010. 1866 20.4 

The infant passes five or six times as much urine per kilo of 
body-weight as the adult ; the child, three or four times as much. 

The infant excretes 0.3 urea per kilo of the body-weight, the 
child, 1.0, and the adult, 0.5. Uric acid is normally present in the 
urine of the newly born infant who excretes 21 milligrammes daily 
(Ruge.j 

Albumin is not present in the normal urine of infants, but if the 
mother has during delivery suffered from eclampsia, the urine of the 
newly born infant may contain albumin. 

Indican is present, in traces, in the urine of the newly born infant. 
It is especially constant in infants suffering from gastro-enteritis, 
and may be present in a number of maladies, especially in forms of 
suppuration. It is present in tuberculosis, but is not of diagnostic 
value (Zamfiresco). 



CYCLIC ALBUMINURIA. 

Postural Albuminuria. ) 
- of tin- form of albuminuria were first published by Vogel, 
Ultzmann, Gull, and Leube. The systematic description was first 
given by Paw. by whom it ha- been carefully studied. 

Cyclic albuminuria occurs principally in children and adolescent.-. 
The characteristic symptom is the appearance of albumin in the urine 
in the forenoon and afternoon, and it- disappearance after a night's 
rest in the recumbent position. It is not present in the morning 
directly after rising, but appears Boon after the upright position bas 
been assumed. The quantity of albumin is not excessive. It may 
disappear from the urine for day- and week-, and again reappear. 



616 DISEASES OF THE KIDNEYS. 

The quantity of albumin does not progressively increase. The urine 
never contains formed elements of the kidney, such as casts. 

There is no doubt as to the existence of this form of albuminuria 
in children, but its significance is a matter of wide diversity of 
opinion. Heubner has lately published some cases, and has collected 
from the literature 22 cases in children from one to fifteen years of 
age. Some authors, among them Heubner, are inclined to give a 
good prognosis in these cases, and to regard them as physiological 
forms of albuminuria. Others, among them Henoch, Leube, and 
Senator, are inclined to regard them as due to insidious changes 
in the kidney following infectious disease. It should be remem- 
bered that after influenza, scarlet fever, or diphtheria, small quanti- 
ties of albumin are, at intervals, present in the urine for months and 
years. There may also be occasional hyaline or epithelial casts and 
a few blood-cells. These disappear either with or without treatment 
of diet and rest, but later reappear. I have seen this occur in 
children in good health. In one case, the child gave a history of 
an attack of influenza. More careful data on the subject are needed. 
In a given case, the urine should be carefully and frequently examined 
for kidney elements. It should be remembered that, in nephritis, the 
albumin in the urine frequently takes a cyclic course (Senator). 



(EDEMA OR HYDREMIA WITHOUT KIDNEY LESION. 

Weak infants who have suffered from chronic gastro-enteric 
catarrh have swelling or an cedematous condition of the dorsum of 
the feet and ankles. There may be slight anasarca elsewhere. There 
is no real kidney lesion ; the condition is one of hydraemia. The 
changed state of the tissues, including the vessels and blood, allows 
of a transudation of serum into the subcutaneous structures. On 
examination, the urine is found to be abundant and of low specific 
gravity, but without evidences of nephritic degeneration. In chil- 
dren of two years of age this condition of slight subcutaneous 
oedema occurs in simple anaemia of a severe type. In these cases 
the skin is yellowish, the ears have a waxy clearness, the eyes have 
an cedematous appearance, and the lips, hands, and feet are puffy. 
The condition is known as hydraemia or hydremic anaemia. 

DYSURIA. 

Dysuria, or difficult and painful micturition, is a condition in which 
there is partial obstruction to the free flow of urine from the urethra. 
It is not uncommon in young infants and children, and may be due to 
a variety of causes. If lithiasis is the cause, there is not only pain in 
passing the urine, but there may, in the intervals, be acute attacks of 



BJEMUTURIA. 617 

pain, due to the passage of calculi along the ureter. Examination 
of the urethra in the male often results in finding a calculus of 
very small size in the anterior penile urethra. In lithiasis, there 
i> sometimes very painful micturition without the formation of cal- 
culi of any size. The minute crystals of uric acid cause a smarting 
sensation as the urine passes over the urethra. In febrile states with 
concentrated urine, the acidity of the urine, and the excess of uric 
acid with free crystal-, cause painful micturition. 

Simple or gonorrhoea! inflammation of the urethra may cause 
difficult and painful micturition. Dysuria is painful at the onset of 
vulvovaginitis. Another condition of congenital origin, which was 
described by Bokai as cellular atresia of the labia, is a very 
common cause of dysuria. It is seen in very young female infants. 
From birth, the urine is passed in drops and with great straining 
and pain. In some cases it is passed without pain, but the condition 
of atresia attracts attention. On gently separating the labia majors a 
thin pinkish-white membrane is seen to occlude the introitus vaginae 
completely. At the urethral end of this membrane, a very minute 
opening is seen, through which the urine filters. These membranes 
can be divided by means of a dull director. It is then seen that the 
hymen and urethra are directly behind the membrane. The opera- 
tion of dividing the membrane is exceedingly simple, and causes 
little or no bleeding. Bokai has described a similar condition in 
boys, which is somewhat less common. It is a cellular adhesion 
of the prepuce and glans penis which not only causes false phi- 
mosis, but also difficult and painful urination. He found that in 
the newly born infant the prepuce was sometimes adherent to 
the tip of the glans penis, and that across the opening of the 
meatus there was a very thin membrane. In other eases, this 
membrane was ruptured, but the prepuce still remained adherent 
to the glans in front, while behind at the corona glandis there was 
retention of smegma and consequent painful inflammation. 

The treatment is division and separation of the cellular adhe- 
sions. Other abnormalities in infant boys, among them diverticula 
of the urethra, may cause dysuria. 



ILEMUTURIA. 

Hematuria i- the passage of blood and its elements into the 
urine, in which blood-cells and coloring-matter are found. The 
condition may occur in the following states : 

(a) Aente nephritis of all forms, especially those complicating 
the infectious diseases, Buch as scarlet fever, measles, typhoid fever, 
and malarial fever. 

(//> Calculi, renal or vesical. 



618 DISEASES OF THE KIDNEYS. 

(c) Malignant growths of the kidney — sarcoma and carcinoma. 

(d) Growths of the bladder — polypus. 

(e) Traumatism in the region of the kidney. 
(/) The ingestion of drugs. 

The color of the urine varies from a slightly smoky amber to a 
deep brownish-red. There may be a deposit of blood-cells and clots 
in the urine. Pure blood with clots is seen in cases of malignant 
tumor of the kidney and calculi of the kidney or bladder. Smoky 
urine is seen in cases of nephritis and drug-poisoning. 



HEMOGLOBINURIA. 

Hemoglobinuria is a condition in which the urine contains the 
coloring-matter of the blood, but, except in rare cases, no red blood- 
cells. The urine is reddish or brownish, and has a high specific 
gravity. It contains albumin. By spectral analysis, the spectrum 
of the blood coloring-matter is obtained. According to Hoppe- 
Seyler, methaemoglobin and not hemoglobin is often the coloring- 
matter present. There are few blood-cells and no detritus. Several 
theories have been advanced to explain the appearance of haemo- 
globin in the urine, that of Ponfick being generally accepted. 
According to that author, either the blood-cells are destroyed by 
some vicious agent or ferment (Ehrlich) and the haemoglobin is 
thus let loose into the circulation, or the haemoglobin is dissolved 
out of the blood-cells and passes into the circulating plasma, leaving 
the cells behind as so-called " shadows." AVhatever the real cause, 
the exciting influences are as follows : 

(a) Cold or exposure to wet. Hoif and Demme have pub- 
lished cases of children with paroxysmal haemoglobinuria following 
such exposure. 

(b) Drugs, such as arsenic, phosphorus, potassium chlorate. 

(c) The infectious diseases, such as malaria and scarlet fever, 
erysipelas. 

(d) Haemoglobinuria has been observed in cases of burns. 

(e) Baginsky has observed haemoglobinuria in children with 
nematodes. 

In the paroxysmal form, each attack is preceded by a chill and 
followed by dyspnoea, palpitations, cyanosis, and severe symptoms 
of collapse. The attack may last a few hours or a few days, the 
duration depending on the course of the primary affection. This 
form has been especially observed to occur in pernicious malaria. 

The treatment consists in the management of the primary excit- 
ing conditions. 



ACUTE NEPHRITIS. 619 

RENAL CALCULI. 

{Uric Acid Infarction; LUhamia.) 

So-called uric acid infarction is found in the kidneys of over 
one-half the infants who die in the first weeks after birth. These 
infarctions are seen in the medullary portion of the kidney as 
golden-yellow or brownish rays which are broader toward the 
papilla. Ebstein found' isolated deposits in the cortex. The in- 
farctions consist of uric acid (Schlossberger). They are sup- 
posed to be due to the destruction of tissue rich in nuclein (cells) 
(Kossel and Horbaczewski). They are found in weaklings, and 
more often in infants who have been born living than in stillborn in- 
fants. During the first weeks of life they are washed out by the 
urinary secretion. Hence the increased uric acid excretion at that 
time. As a rule the condition gives no symptoms. It is not uncom- 
mon for the diapers of the infants to be stained red, and in older 
children there may be the so-called brick-dust deposit in the urine. 
In these cases there may be a history of severe colicky attacks. In 
other cases the infant or child experiences pain on urination and cries 
piteouslv. Some older children will run about in pain and grasp the 
penis. In all such cases I examine the diapers for concretions. Fail- 
ing to find these, I carefully examine the urethra. In several cases 
I have found an oval calculus of the size of a rice-seed, imbedded 
in the canal of the penile portion of the urethra. These cases have 
attacks of pain extending over months, and probably caused by the 
passage of the calculi from the kidney through the ureter, the blad- 
der, and urethra. The calculi are easily extracted with long-bladed 
forceps. In one of my cases of hematuria, in a boy three years 
of age, there were several attacks lasting for days, but no distinct 
history of pain. The urine contained blood coloring-matter, some 
blood-cells, and a few hyaline casts, which it was difficult to find. 
The diagnosis was obscure until a few small calculi were found in the 
urine. Urotropio given in small doses caused a cessation of symp- 
toms. 

ACUTE NEPHRITIS. 

.1. Acute Parenchymatous Nephritis or Acute Exudative Ne- 
phritis (Delafield) ; Tubular or Glomerular Nephritis. 

II. Acute Diffuse Nephritis or the Acute Productive Nephritis 

(Dela field). 

The etiology of both form- of acute nephritis is the same. 
There is scarcely an acute infectious febrile disease which may 
imt give rise to acute nephritis. It complicates or follows scarlet 



620 DISEASES OF THE KIDNEYS. 

fever, measles, influenza, diphtheria, infectious angina, pneumonia, 
rheumatism, typhoid fever, sepsis of all kinds, variola, parotitis, 
malaria, and congenital syphilis. The frequency in scarlet fever 
of the (edematous forms with anasarca has led to the belief that this 
disease was most often complicated by nephritis. If the paren- 
chymatous form is included, the condition will be found to be very 
frequent in other infectious diseases, but it is often unrecognized. 
The essential causes of acute nephritis are micro-organisms or their 
toxins. Thus in the various diseases, the Diplococcus pneumonia?, 
the typhoid bacillus, streptococci of various kinds, staphylococci, 
and the Bacillus pyocyaneus, have among other bacteria been found 
in the kidney. On the other hand, in diseases such as diphtheria, 
the toxins of the bacteria are the cause of the parenchymatous or 
diffuse nephritis (Ftirbringer, Roux, Councilman). If the toxins 
are formed in the body, the infections are said to be autochton or 
endogenous. The irritating toxin may be introduced from with- 
out, as in chloroform or ether narcosis, and the ingestion of drugs 
(ectogenous). The rdle played by cold as a causative factor is still 
a matter of speculation. Its mode of action, whether reflex, through 
the circulation, or by causing changes in the blood, is still obscure. 

Morbid Anatomy. — Acute Parenchymatous or Exudative Nephri- 
tis (Delafield). — This is an acute inflammation of the kidney, in 
which the principal changes occur in the epithelium of the tubules 
and Malpighian tufts. The kidneys are larger than is normal, and 
succulent. The capsule can be stripped from the surface, which is 
red, grayish, and punctate in spots. All the changes are most 
marked in the cortex of the kidney. Evidences of inflammation 
are found in the tubes, stroma, and glomeruli. The epithelium of 
the tubes is flattened, granular, and fatty, or in a condition of coag- 
ulation-necrosis. The lumen of the tubules may be empty or may 
be filled with desquamated epithelium or with coagulated masses 
(casts) of a hyaline character. Delafield describes the tubes, in severe 
cases, as filled with leucocytes and blood-cells. The tubes may be 
uniformly dilated. 

The changes in the glomeruli may be so slight as to be scarcely 
noticeable. The cavities of the capsules sometimes contain coagu- 
lated matter and red and white blood-cells (Delafield). In marked 
cases, there are desquamation of capsular epithelium and increase of 
nuclei. The swelling and proliferation of cells sometimes change the 
appearance of the tuft so that the outlines of the individual capillaries 
are lost. The stroma is infiltrated with serum, and in severe cases 
there are in the cortex small .collections of white blood-cells (pus). 

The changes in acute diffuse nephritis, or the acute productive 
nephritis of Delafield, are more serious and permanent. According 
to Delafield, the kidneys are large, and at first smooth and later 
rough. The cortex may be mottled yellow and red ; the pyramids 



ACUTE NEPHBTTIS. 621 

are red. In this form of nephritis there are the changes found in 
exudative nephritis, and also a growth of connective tissue in the 
stroma and an increase of the capsule cells of the Malpighian bodies. 
These changes involve symmetrical strips in the cortex, which follow 
the lines of the arteries (Delafield). The Malpighian bodies show 
an enormous growth of capsule cells with compression of the tufts. 
If the nephritis is acute, the interstitial tissue is augmented with 
newly formed cells and basement substance. There is a new growth 
of connective tissue between the tubules ; the walls of the arteries 
are thickened. In the capsule oi' the Malpighian tuft, there is a 
growth of cells which compress the tuft of vessels. These and the 
vessels are in turn converted into small balls of fibrous tissue (Dela- 
field). In addition there may, in the acute forms of nephritis, be 
hemorrhages throughout the kidney substance. 

Symptoms. — In the forms of parenchymatous nephritis which 
complicate the febrile infections diseases, influenza, pertussis, angina, 
and gastro-enteritis, either the symptoms of the primary disease 
mask those due to the kidney lesion or the nephritis may be so mild 
as to give no symptoms. Thus in the parenchymatous nephritis 
which complicates or follows influenza, there are after the attack has 
passed n<> symptoms referable to the kidneys, yet on examination 
the urine shows a trace of albumin, hyaline and a few epithelial 
casts, and an occasional red blood-cell. In these cases there is no 
oedema of the tissues, no headache, and the children are apparently 
well except for the changes in the urine. These may at first be 
quite marked. After a few months the albumin may only appear 
occasionally; the casts and blood disappear for weeks and then 
reappear. For weeks or months the children may have no consti- 
tutional symptoms. In the parenchymatous nephritis, which is seen 
in severe form- of gastro-enteritis and dysentery, the signs in the 
urine of marked nephritis are albumin, easts of all kinds, and 
blood-cells (Parrot, Pischl, Czerny, Koplik, and Morse). Although 
Czerny trace- ;i certain form of dyspnoea to the influence of uraemia 
in these cases, n<> distinct set of symptoms due to the kidney can 
yet be formulated. It is true that there are terminal anasarca, SU] 
pression of urine, and vomiting, but the presence of all these 
be ixplained by the severity of the intestinal lesions. 

Changes in the Urine. — In all the diseases above mentioned, the 
parenchymatous oephritii may in infant- and children be evinced by 
diminution of the quantity of urine, or the presence of a trace of 
albumin, or a few hyaline or epithelial caste and blood-cells. The 
quantity of urine may. however, be normal. In other cases, the 
albumin i- more marked and the casts much more numerous. Elena! 
epithelium i- also present. Leucocytes are rare. 

In the diffuse or productive form of nephritis in infant- and 
children, the symptoms are marked. In some forms of nephritis 



»- 
nav 



622 DISEASES OF THE KIDNEYS. 

complicating scarlet fever the lesion never advances beyond the 
parenchymatous stage, and at that period the symptoms are either 
not present or not noticeable. If the nephritis is more marked, 
however, it is noticed at the end of the third week that the patient 
is somewhat pale, that the face is a little swollen especially about 
the eyes, and that there is very slight oedema of the general surface. 
In these cases it is possible at the end of the period of eruption, 
to find a slight trace of albumin in the urine and a few hvaline and 
epithelial casts. With the onset of the anasarca the albumin 
increases in quantity, the casts in number, and a few blood-cells are 
found. The quantity of urine is diminished, but in the mild forms 
not markedly so. A boy of six years may pass half the normal quan- 
tity. There is no headache, and only a few obscure pains in the 
joints. There is occasionally slight pain in the region of the 
kidney. The temperature is normal or may at intervals of several 
days rise a degree or a degree and half above the normal. The 
nephritis is probably of the mild diffuse type. In three weeks the 
mild anasarca disappears, the anaemia improves, and the urine be- 
comes normal. 

In the more severe cases there is a rise of one or two degrees 
in temperature, and the patients have marked general anasarca. If 
old enough, they complain of headache, they vomit, and show marked 
decrease in the number of respirations and pulse, the irregularity 
of pulse being of a purely ursemic character. In some cases there 
are effusion into the chest (hydrothorax) and abdominal ascites. 
The quantity of urine is much diminished, there being only one 
or two ounces in twenty-four hours. The specific gravity is high ; 
the urine contains blood, leucocytes, and casts (hyaline, granular, 
and epithelial), with blood cells. Under treatment, the vomiting, 
headache, and anasarca subside, the quantity of urine increases, the 
number of casts and blood-cells diminishes, and the patient makes 
a good recovery. In other cases the initial anasarca becomes more 
marked, there being considerable oedema of the whole surface ; the 
urine is entirely suppressed ; the vomiting and headache increase ; 
convulsions set in ; there are several attacks of eclampsia ; the 
patient becomes comatose, and may die of uraemia, or after one or 
two attacks of eclampsia, the symptoms may abate and recovery 
take place. 

There is a very fatal form of diffuse nephritis which occurs on 
the fourth or fifth day of malignant scarlet fever. On the third day, 
at the height of the eruption, the patient passes into a delirious, 
semi-conscious state. The quantity of urine is much diminished ; 
its specific gravity is high ; casts of all kinds and blood are present. 
The urine may finally be totally suppressed. There is no (edema of 
the surface. Coma and convulsions set in. The patient succumbs 
to the intense general toxaemia and to its effect on the kidneys. In 



ACUTE NEPHRITIS. 623 

these cases the kidney symptoms cannot be separated from those 
caused by the general intoxication. 

Individual Symptoms. — The Vomiting. — The vomiting in scar- 
latinal nephritis is rarely distressing, and subsides in a short time. 
It is n<»t a constant symptom, nor is it of serious import. 

The HEADACHE is not a very marked symptom in children. 

CEdema is present in a large proportion of cases, and is marked 
in the severe ones. It may occur with hydrothorax, ascites, and 
hydropericardium. It may affect only the face, or the lower extrem- 
ities alone. It may he so intense as to cause bursting of the skin 
and tlie escape of serum through the fissures. It may affect one 
half the body more than the other (Henoch). Under all these con- 
ditions, the outlook is serious. 

The PULSE is sometimes inordinately slow. It may he more 
rapid than normal, and may show marked irregularity. 

The heart may, as was pointed out by Henoch and Friedlander, 
he the seat of hypertrophy and dilatation. There may be compli- 
cating endopericarditis. 

The LUNGS may be the seat of pneumonia, or (edema of the 
lungs may suddenly develop. There may be complicating pleuritis. 

There may be CONSTIPATION or more or less diarrhoea. 

There are cases in which the TEMPERATURE is normal or sub- 
normal during the whole course of the disease. In the cases in 
which there are sudden eclamptic seizures, the temperature may mount 
to 104° F. (40° C.)during the attacks. On account of the rupture 
of a bloodvessel in the brain during the eclamptic seizures, there is 
in many cases, after the subsidence of the uremic symptoms, aphasia, 
or hemiplegia of a more or less permanent nature. 

Patient- with nephritis succeeding scarlet fever develop fainting 
-pell- with cyanosis, galloprhythm, and all degrees of cardiac weak- 
ness. It is difficult in such cases to know whether to attribute 
these symptoms to the nephritis or to myocarditis which is the 
result <>f the scarlet fever. 

Tin: URINE. — The general characteristic features of the urine in 
acute diffuse nephritis of scarlet fever have been given. Suppression 
may take place suddenly. The urine may not have contained coagu- 
labie albumin or casts, and the quantity may have been normal. 
The common notion that uremia or eclampsia can supervene only if 
the quantity of urine is diminished, is erroneous. Even if the 
quantity i- above the normal and the urine contains little albumin 
and few casts, eclampsia may supervene with fatal results. An in- 
crease in the quantity of urine above that of the normal is an 
unfavorable symptom. The quantity of urea passed is always the 
crucial test. There are cases in which blood appears in the urine 
and in which there is true hemoglobinuria, which may give rise t<> 
irritation of the kidney. In other words, the haemoglobinura is 



624 DISEASES OF THE KIDNEYS. 

primary, the nephritis secondary. The quantity of albumin in the 
urine varies greatly ; it may only amount to a trace or be sufficient 
to cause the urine to become solid when boiled. 

The Primary Forms of Acute Nephritis. 

The question has arisen : Can nephritis be primary ? If nephritis 
is the result of some form of infection, it cannot be primary. 
Henoch, Heubner, Bouchut, Bartels, Loos, and Holt have published 
cases in nurslings, the origin of which could not be traced. These 
occurred in infants from five weeks to one and a half years of age, 
who suddenly developed marked anasarca and vomiting, with sup- 
pression of urine. Some of the cases had a febrile movement of a 
remittent type. The majority of them were fatal. Their exact 
nature is still unknown. Uhlenbrock has recently collated all the 
cases in the literature, but has thrown no light on the subject. On 
autopsy, a few cases have shown a parenchymatous nephritis. 

Course. — The majority of cases of parenchymatous or exudative 
nephritis recover. The prognosis of the diffuse or productive form 
is more serious, but in exceptionally mild cases recovery may take 
place. Other cases make an apparent recovery. After the symptoms 
of oedema and anasarca have disappeared, anaemia remains. The 
albumin in the urine may disappear and reappear. In six months 
or a year, general anasarca may set in with all the symptoms of an 
acute exacerbation of the disease. The patient may eventually re- 
cover from the attack, but as a rule others of the same kind follow, 
and the condition of chronic nephritis results. 

Duration. — The acute forms of parenchymatous or diffuse neph- 
ritis last from two to six weeks. The parenchymatous forms are 
sometimes evanescent, the marked symptoms lasting only a week. 

Chronic Diffuse Nephritis. 

(a) Chronic Productive Nephritis, (b) Chronic Nephritis without Exudation (Delafield). 
The forms of chronic diffuse nephritis are the same in childhood 
as in adult life. They usually occur late in childhood. Thus one 
case of chronic diffuse nephritis in a girl of fourteen years of age 
dated from an attack of scarlet fever at the age of eight years. 
At autopsy there was found a diffuse nephritis of the productive 
variety (large white kidney). In another case, a boy of twelve 
years, with diffuse nephritis of the non-productive variety (small 
cirrhotic kidney), had had an attack of scarlet fever at the age of 
five years. He had no anasarca in the course of the nephritis. 
Active symptoms of headache and vomiting appeared a year and a 
half before his death. The quantity of urine was above the normal 
and there were a few hyaline casts. At autopsy a small kidney was 



CHRONIC DIFFUSE NEPHRITIS. 625 

found. Thus there may in children be two forms of chronic nephri- 
tis following scarlet fever or any other infectious disease. Adults 
present symptoms referable to the eye, such as neuroretinitis, which 
I have not met with in children, and which must he exceedingly 
rare. Neither have I seen in children the emphysema met in 
adults. The heart may he hypertrophied and dilated in children 
as in the adult. They may have endocarditis and pericarditis with 
pleurisy. 

Treatment. — The forms of parenchymatous or exudative neph- 
ritis which so frequently occur as accompaniments of the acute 
febrile disorders, pneumonia, typhoid fever, influenza, etc., need little 
or no treatment. There are no symptoms referable to the kidney. 
Nephritis accompanying acute gastro-enteritis is best treated by 
remedies directed toward the primary affection. The quantity of 
urine is sometimes diminished. It contains casts of all kinds. 
Rectal enemata of saline solution at a temperature of 108° F. 
(42.2° C.) are then of great utility, not only in supplying fluid to 
a depleted circulation, but also in stimulating the circulation and 
therefore the kidney secretion. Drugs which might still further 
compromise the condition of the kidney should not be given for 
the intestinal affection. Hot baths are. of great utility, 105° F. 
(40.5° C). 

In the partial or complete suppression of urine seen in the first 
few days of the malignant forms of scarlet fever, more active treat- 
ment is required. When the temperature is high, the pulse rapid 
and weak, the patient unconscious or delirious, and the urine dimin- 
ished or suppressed, I administer high and large rectal enemata of 
water at a temperature of 108° to 110° F. (42.2° to 43.3° C), as 
recommended by Kemp. These should not be given to children 
with a double-current tube, but simply as enemata. About a quart 
of saline solution is thrown into the rectum at very low pressure. 
A fountain bag syringe is utilized for this purpose. These enemata 
stimulate the heart and circulation and supply the system with 
normal fluid. To stimulate the skin, the warm baths are preferable 
to cold ones. Patients are frequently much depressed by cold packs 
or bath- given to reduce the temperature. The temperature of the 
bath should be at least 105° F. (40.o° C), and the patient allowed 
t<» remain in it five or ten minutes, according to the state of the 
pulse. 

In acute cases the anasarca will, as a rule, take care of itself. If 
it is extreme, Senator advises the administration of diuretics in acute 
as well as chronic nephritis. Some authors recommend diuretin and 
digitalis in form of infusion, a drachm being combined with an agree- 
able alkali, such a- citrate of potassium. The pulse should be 
watched. If it is low, the digitalis is suspended. I do not utilize 
whiskey or alcohol in the- cases. In acute diffuse nephritis and 

40 



626 DISEASES OF THE KIDNEYS. 

in productive nephritis similar to that of scarlet fever, the ursemic 
symptoms, the oedema, and the kidneys are treated. Vomiting 
is a ursemic symptom which is prominent at first. If the patient 
vomits everything ingested, no food should be given by mouth. 
The patient is nourished by rectum by means of somatose or 
nutritive enemata. The headache needs little treatment. Bromide 
and a small dose of chloral or trional are given for restlessness at 
night. In the forms of nephritis, generally subacute, in which there 
are oedema amounting to anasarca, and diminution of urine, baths 
and diuretics are beneficial. The anasarca is sometimes scarcely 
noticeable, and the quantity of urine little diminished. There are 
usually a few hyaline and epithelial casts, and also blood-casts. The 
patient is kept in bed and put on a milk diet. The bowels are kept 
open by means of Vichy water given in liberal quantities, or by 
Carlsbad salts. A child between four and six years of age should 
take half a drachm of the salts once a day. Some mild diuretic, 
such, as citrate or acetate of potassium, is given. The pulse may 
be 80 or 90, and digitalis is therefore not given. Under this mild 
therapy the anasarca subsides, the albumin diminishes, and the urea 
and quantity of urine increase. Milk also tends to increase the 
quantity of urine. A bath at 104°-105° F. (40° C) is given every 
day or every second day according to the indications. The diaphoretic 
effects of vapor baths are less marked. In some of the severer cases 
the urine is greatly diminished, the anasarca extreme, the pulse 
and respirations are increased, and the temperature maybe elevated. 
The anasarca is then treated by a daily warm bath, in which the 
patient remains for five minutes, and is then wrapped in a warm 
dry blanket to promote diaphoresis. A warm rectal enema at the 
temperature above mentioned is given twice daily. The kidneys 
are stimulated by means of digitalis and acetate, citrate, or tartrate 
of potassium. The digitalis is given in form of the infusion, gss- 3J 
with 3 to 8 grains of the potassium salt, three or four • times daily. 
The pulse is closely watched and not allowed to fall too low. The 
bowels are kept open by the daily administration of cathartics. If, 
as frequently happens, the heart becomes weak, sparteine or liq. 
ammoniae acetatis and nitroglycerin may also be given. I do not 
administer preparations of musk or camphor in nephritis. Con- 
vulsions are best controlled by means of chloroform. Warm baths 
and high warm enemata are also useful. Bromide and chloral are 
also given by rectum, as in ordinary eclampsia. 

In convalescence the question arises, When shall diuretics be dis- 
continued ? As soon as the quantity of urine is above the normal, 
they are of no further value. The baths and enemata are continued 
as long as there is the least oedema of the surface. Warm enemata 
should not be continued after the urine has increased to the normal 
amount. Ordinary enemata are then given for the purpose of aiding 



HYDROXEPHROSIS. 627 

the cathartics in keeping the bowels open and clear of fecal accu- 
mulations. 

Rest in bed should be continued until there is no palpable albu- 
min reaction. Meat and vegetables are then added to the diet list. 
If anaemia is present, a readily assimilable form of iron, such as the 
peptonatej is given. Casts will appear in the urine far into conva- 
nce. The patients may, however, be allowed to be up if they 
bear the change well. A too protracted stay in bed is sometimes 
exhausting in summer. If symptoms of anasarca and other signs 
of nephritis recur, the treatment is the same as in primary acute 
attacks. The treatment of chronic nephritis in children does not 
differ from that followed in the adult. 



NEW GROWTHS OF THE KIDNEY. 

Thirty-eight per cent, of all the reported cases of kidney tumors 
occurred in children (Doderlein, Lewi). The following growths are 
here considered: 1. Cysts of the kidney; 2. Tuberculosis of the 
kidney ; 3. Carcinoma of the kidney ; 4. Sarcoma of the kidney. 

Cysts of the Kidney. 

Cy>ts of the kidney are in children usually of congenital origin. 
They are formed in the second half of intra -uterine life. They are 
bilateral, only 1 in 60 being unilateral (Lejars). The kidney is 
made np of greater and smaller cysts. The cystic formations may 
be present to the entire exclusion of kidney tissue. The cysts may 
attain the size of a child's head and seriously obstruct delivery. 
They are of anatomical interest only, since infants with such cysts 
present other abnormalities and die soon after birth. 

Hydronephrosis. 

Hydronephrosis is either congenital or acquired. If acquired, it 
OOCUT8 late in childhood. The congenital form is due to stenosis in 
some part of the urinary tract. Hydronephrosis i< as a rule uni- 
lateral. If it occurs after birth, it may be due to obstruction by 
calculi or to uric acid infarction of the kidney. The healthy kidney 
is physiologically enlarged. The acquired form is due to obstruc- 
tion by calculi or to tumors pressing on the ureters. At first the 
pelvis of the kidney, then its tissue ifl encroached upon in the 
gradual dilatation. Finally the shape of the kidney is lost. There 
IS a large fluctuating tumor which may or may not be painful. 
When ir is punctured, there is withdrawn a fluid which contains 
albumin, epithelium, urea, uric acid, and which has a low specific 



628 DISEASES OF THE KIDNEYS. 

gravity. In some cases there occurs what is known as intermittent 
hydronephrosis. The contents of the tumor are emptied spontane- 
ously, but reaccumulate. The diagnosis rests on the presence of a 
fluctuating tumor containing the fluid, and urine constituents. 
Cystoscopy may in some cases reveal obstruction of the ureters. 

Cysts must anatomically be differentiated from the condition 
of hydronephrosis. Cysts are new growths (Senator) ; in that 
respect they differ from the cystic condition of hydronephrosis. It 
is not possible clinically to differentiate congenital cysts of the 
kidney from congenital hydronephrosis. 

Sarcoma of the Kidney. 

Sarcoma of the kidney occurs in children as a primary growth. 
In the statistics of Eosenstein and Senator two-thirds of the cases 
occur before the tenth year. It is more frequent in females. The 
left kidney is more commonly affected. Sarcoma occurs in the newly 
born infant. The presence of muscle, bone, and cartilage tissue in 
these growths supports the theory of their congenital origin (Jacobi). 
The anatomical nature of the growth varies widely. It may be 
round-celled or spindle-celled sarcoma, a fibro-sarcoma, myo-sarcoma, 
angio-sarcoma, melanotic sarcoma, or adeno-sarcoma. There may be 
metastases. The tumors sometimes attain a weight of fifteen pounds. 

The symptoms do not differ materially from those of carcinoma 
of the kidney, nor is sarcoma of slower growth. In many cases the 
pain, hematuria, and tumor follow a traumatism. Hematuria is 
not, as in. carcinoma of the kidney, a constant symptom. I have 
seen cases of both carcinoma and sarcoma of the kidney in young 
children without hsematuria or growth elements in the urine. Ascites 
is present in more than one-half the cases (Lewi). 

Diagnosis. — A malignant growth in a child may be surmised to 
be a sarcoma, since those growths are more frequent in children than 
carcinomata. Swelling of the lymph-nodes may be present in 
sarcoma as well as in carcinoma. Histological elements in the 
urine are rare. Von Jaksch has mentioned the presence of small 
round cells (sarcoma cells), but their significance is not as yet 
determined. Puncture for diagnostic purposes is dangerous, and 
if performed at all should be done posteriorly in the lumbar region 
(extraperitoneal). In sarcoma of the kidney, as in all growths of 
that organ, the colon is pushed in front of the growth (Plate XXX.). 

Carcinoma of the Kidney. 

Of 449 cases of carcinoma of the kidney (Rohrer, Ebstein, 
Lachman), 157, or almost 35 per cent., occurred in children under 
the tenth year. Monti tabulated 50 cases, and found that more than 



PLATE XXX. 




Sarcoma of the Kidney. Child six 
years of age. Irregular contour of the 

abdominal tumor. 



CARCINOMA OF THE KIDNEY 



629 



50 per cent, occurred in children under the age of two years. The 
youngest patient was twelve months of age. It is more frequent in 
males. As a rule the right kidney is affected. In children, the growth 
is apt to attain great size. Guillet found that the average weight 
was eight and one-half pounds. By reason of the great weight of the 
growth, the kidney may sink from its normal position and lie trans- 
versely across the vertebral column. The growth is a primary one, 
The medullary carcinoma is the prevailing type ; the scirrhous is 
next in order of frequency. The disease may be secondary to carci- 
noma <>f the suprarenal capsule or of the retroperitoneal glands. The 
liver, the lungs, and the inguinal lymph-nodes may be secondarily 
involved. 

Fro. 167. Fig. 168. 




Enlargement of tin- kidney. 

Anterior palpable tumor beneath the liver. Posterior area <.f flatness in the lumbar 

region, giving 8 palpable tumor between the 
border of the ribs and the crest of the ilium. 



Symptoms. — The chief symptoms are pain, haematuria, cachexia, 
and enlargement of the kidney. Guillet found thai haematuria was 
the first symptom in one-half the cases. The quantity of blood 
passed may be very -mall, or so great as to amount to a dangerous 
hemorrhage. The urine may be red or chocolate colored, and may 
contain clots of blood or caste of the ureter-. Frequent micturition 
is sometimes an early symptom. In other cases there is no haema- 



630 DISEASES OF THE KIDNEYS. 

turia, the cachexia, emaciation, and tumor being the first symptoms. 
In younger children the hematuria is frequently absent. The kidney 
is in these cases protected from traumatism. The tumor is some- 
times so great as to cause displacement of the organs. In Fiirb rin- 
ger's case the heart was displaced to a situation beneath the clavicle. 
The abdomen is distended, and the colon is pushed in front of the 
growth and is indicated by a tympanitic area at one side of the 
median line of the tumor. On the right side, the tumor appears 
beneath the liver, and in narcosis can be felt in that situation as a 
distinct mass. The tumor has an uneven surface. The urine may, 
in addition to blood, contain histological elements of the growth. 
This does not occur so frequently in carcinoma of the kidney as in 
tuberculosis of that organ. 

Duration. — The progress of the growth is much more rapid 
in children than in adults. In the former subjects the duration of 
the disease is from ten weeks to fourteen months (Roberts). 

Diagnosis. — In children, while the diagnosis of a morbid growth 
of the kidney can be made, it is not possible to differentiate be- 
tween the symptoms of carcinoma and those of sarcoma. It can- 
not be determined, from the symptoms, whether the growth is a 
simple carcinoma, an adeno-carcinoma, or an adeno-sarcoma. The 
symptoms of a malignant growth of the kidney are pain, hematuria, 
tumor, and cachexia. A cyst of the kidney may be confounded 
with a malignant growth. Cysts are congenital, and as a rule 
bilateral. This is also the case in hydronephrosis. In the latter 
condition extraperitoneal puncture of the tumor may give a fluid 
with urine constituents. In carcinoma of the kidney, puncture for 
diagnostic purposes is not devoid of danger. 

Tuberculosis of the Kidney. 

Tuberculosis of the kidney is rarely if ever primary. Senator 
asserts that it never occurs as a primary lesion. There are patho- 
logically two forms — the miliary and the cheesy. The miliary 
form is more frequent in children, the cheesy in later life. In 
the miliary form, the kidney tissue is the seat of an eruption of 
miliary tubercles. In the cheesy form, tuberculous nodules may 
entirely replace the substance of the organ. The cheesy form is as 
a rule secondary to tuberculosis of the genitals — the epididymis in 
boys and the tubes in girls. The symptoms do not differ materially 
from those of the same condition in adults. In the miliary form 
there are no symptoms. In the cheesy variety there are dysuria, 
strangury, vesical tension, pain in the region of the kidney, 
emaciation, and fever. The urine contains albumin, blood, epi- 
thelium, and pus cells, and is acid in reaction. Tubercle bacilli are 
sometimes found. 



PYELITIS— PYELONEPHRITIS. 631 

The diagnosis rests on the presence of tubercle bacilli in the 
urine, an enlarged palpable kidney, hematuria, and tuberculosis of 
other organs — the genitals or the lungs. 



Treatment of New Growths of the Kidney. 

The treatment of new growths of the kidney is within the prov- 
ince of the surgeon. The congenital cysts are of scientific interest 
only. If there is reason to believe that there is congenital hydrone- 
phrosis which is unilateral only, surgical interference is indicated. 
Sarcomata and carcinomata should be treated surgically if there is 
reason to believe that there are no metastases in the liver or else- 
where. Tuberculosis of the kidney is treated more from a general 
standpoint. If there is tuberculosis elsewhere, palliative treatment 
alone must suffice. Isolated tuberculosis of one kidney is a rare 
condition which necessitates extirpation of the organ. If it is 
impossible to determine the proper treatment, an exploratory opera- 
tion is indicated. 



PYELITIS— PYELONEPHRITIS. 

This is a very rare affection in infancy and childhood. Calculus, 
tuberculosis, and irritating drugs, are etiological factors. It occurs 
as a complication of the infectious diseases — scarlet fever, measles, 
variola, and typhoid fever. It may be caused by infection from a 
vulvovaginitis or by coli bacteria entering through obscure chan- 
cels. The inflammation of the pelvis of the kidney may extend 
to the tissue of the kidney itself. Small abscesses are present 
in the cortex and there is degeneration of the parenchyma of the 
kidney. 

The symptoms consist of fever, of an intermittent or remittent 
type, with recurrent rigors. The fever may alternate with sub- 
normal temperatures. The urine is characteristic. It is of normal 
quantity, and low specific weight, is acid in reaction, milky in 
appearance, and contains pus, mucus, and albumin. Microscopi- 
cally there are casts, leucocytes, and bacteria. The bacteria present 
in recently voided urine include the coli group, Bacterium lactis, 
proteus, and Bacillus pyocyaneus (Baginsky). It is characteristic 
of this condition that the pus may suddenly disappear from the 
urine through occlusion of the ureter on the affected side by calculi, 
fibrin, or inspissated mucus. It may reappear after a time. Ema- 
ciation and periarticular or intermuscular inflammation are also 
sometimes present. 

Prognosis is influenced by the causal agent. Simple coli-pyeli- 
tis may retrograde within a few week- and result in recovery. The 



632 DISEASES OF THE KIDNEYS. 

chronic form may last for months. Other forms may lead to irre- 
parable inflammation and degeneration of the kidney. 

Treatment. — If the condition does not improve under treatment 
of rest, milk diet, and diuretics, surgical interference may become 
necessary. 

PERINEPHRITIS AND PARANEPHRITIS. 

This condition is rare in infancy and childhood. It is not 
always possible to determine the cause. If such is the case, the 
disease is called primary. As a rule, it is secondary to traumatism 
in the lumbar region, to pyelitis, or to pyelonephritis. It may 
occur in septicopyemic processes, and I have seen it follow the in- 
fectious diseases, notably scarlet fever. Of 166 cases collected by 
Nieden, only 26 occurred in children. One case occurred in an 
infant five weeks old. Gibney's cases ranged from one and a half 
to ten years of age. The condition is more common on the left side. 
The pus may burrow behind the liver or spleen, or find its way 
downward, forming a mass simulating a cold abscess or a peri- 
typhlitic abscess. It may perforate into the pelvis of the kidney, 
the intestine, peritoneum, vagina, or diaphragm, or, may pass along 
the ileopsoas muscle, and find its way to the hip, and thus appear 
externally. The kidney may be involved because of its contiguity 
to the seat of the process. Pleuritic metastases and amyloid degen- 
eration may finally result. 

The symptoms are usually obscure. The fever is intermittent 
or remittent. Young children do not as a rule complain of pain. 
The first intimation of the nature of the disease is the appear- 
ance of a swelling in the lumbar region. On bimanual palpa- 
tion, a tumor which is fixed, tense, and does not move with respira- 
tion, is felt deep under the liver, in the region of the caecum and 
ascending colon on the right side, or underneath the spleen on the 
left. Gibney has described these, cases and shown how they may be 
easily mistaken for cases of cold abscess. The thigh of the affected 
side is held in a condition of semiflexion. 

The treatment is surgical. 



ENURESIS NOCTURNA AND DIURNA. 

This is a functional neurosis of the bladder in which the urine 
is passed involuntarily, and, as a rule, at night during the first hours 
of sleep. It may, however, be passed at any time during the night. 
Some patients have at times no control over the bladder during the 
day (diurna). Some have enuresis every other night or only once 
or twice a week, and others suffer from the affection every night. 



VULVOVAGINITIS. 633 

Oases of enuresis should be differentiated from those in which there 
is a complete paresis of the sphincter vesicae. In the latter case the 
urine simply Hows away. These arc cases of disease or anomaly 
of the cord (spina bifida). In enuresis the children may in other 
respects he in good health. There is frequently a nervous condition. 
In some cases there i> lithiasis or stone in the bladder; in others the 
etiological factor i- Oxyuris vermicUlaris, obstipation, tumor of 
the bladder, or vulvovaginitis. Cystitis and adenoids have been 
regarded as causal. In the majority of cases no cause can be found. 
The condition follows the exanthemata. In boys it usually disap- 
pears toward the sixteenth year. I have seen ft persist in girls 
into adult life. Its treatment becomes a very serious problem. 

The diagnosis is not difficult. The urine should be carefully 
examined for evidences of Lithiasis, cystitis, glycosuria, nephritis, and 
nematodes, and the bladder for stone. The diagnosis is not made 
in infants and very young children. In the latter the enuresis is 
often only apparent. They do not know how to indicate their 
wants. 

Treatment. — The urine should be passed before retiring. The 
patients should take little liquid at the evening meal. The foot of 
the bed is raised so that the head is slightly lower than the pelvis. 
The drugs most utilized are ergot and atropine. The former is 
given in the fluid extract, minims x to xxx (0.6 to 2.0) t. i. d. Atro- 
pine is given before retiring in a solution (grain j to sij ; 0.0G to 30.), 
a drop for every year of the age (Watson). It is efficient in many 
cases, but in some children distinctly dangerous. I had one case 
in which I gave one-half the above dose. The child, five years of 
age became -lightly delirious and tried to walk out of a window. 
Many cases will improve, only to be subject to relapses. Marion 
Sim- bas shown that enuresis in young girls may be due to an 
intolerant and very small, contracted bladder. In such cases, he 
advises gradual dilatation of the bladder by injecting the organ 
with increasing quantities of an indifferent fluid. It' treated in 
this way, the bladder will eventually retain urine. Most of the 
s resist all methods of treatment. 



VULVOVAGINITIS. 
i nital Jl/i nnorrhaca.) 

The term vulvovaginitis, or, a- it i< now called, urogenital blen- 
norrhoea, refers t-» a gonorrhoea] inflammation of the genital tract in 
children. Before describing the condition it is necessary to refer to 
catarrhal conditions which are not gonorrhceal, and which are present 

in the normal >tatc 

Epstein ha- shown that in the newly born infant there is a 



634 DISEASES OF THE KIDNEYS. 

physiological and normal discharge from the vagina. It is an adhe- 
sive, mucoid discharge containing epithelial cells and micro-organ- 
isms. A few days after birth, this discharge assumes a purulent 
and, in icterus, an icteric hue. No leucocytes are found in the dis- 
charge. In two weeks it ceases and the parts appear normal. This 
form is not gonorrheal . A second condition which I have noted in 
very young children is the result of uncleanliness, lithiasis, irritation 
caused by Oxyuris vermicularis, or masturbation. The parts are 
reddened and eroded, and are bathed with an abnormal serous dis- 
charge. There may be a few erosions around the introitus. These 
cases recover with ordinary care and removal of the source of irri- 
tation. Pus is rarely secreted. 

A second group of cases occurring in young female children 
includes those of vulvovaginitis of the simple catarrhal type. These 
have a scanty or profuse purulent discharge from the vagina, vulva, 
and urethra, which presents clinically all the features of the specific 
gonorrheal group, but is not gonorrheal. The condition is not of 
infrequent occurrence. The urethral orifice is swollen and red. The 
hymen is also swollen and inflamed. The discharge is thin and 
milky, or greenish and viscid. Microscopically, it shows in the pus- 
cells bacteria and diplococci in groups, but these do not show either 
by culture or on staining the characteristics of the gonococci. The 
history of such discharges is singularly similar to that of the gonor- 
rheal form. Urination is painful, and the discharge persists even 
under careful treatment. In one case of this kind I have seen an 
inguinal bubo. The catarrh, like the gonorrheal form, affects the 
urethra, vulva, vagina, and cervix uteri. I am convinced that the 
discharge is infectious and communicable from one child to another. 
It may last for months and again recur. Its exact etiology 
is still unknown. Uncleanliness, infection from a vaginal dis- 
charge, marasmus, the infectious diseases, or frail health may be 
trie cause. 

Urogenital Blennorrhoea. — These cases have been described by 
Pott, van Dusch, Spaeth, Cahen-Brach, Epstein, and others. 

Etiology. — This form may occur in newly born infants (Epstein) 
or in older infants and children. Epidemics may occur in hospitals 
(Frankel). The avenue through which the disease is conveyed is 
still unknown. It occurs in all walks of life. In some cases there 
is a history of the child's having slept with the mother. In others, 
there is no such history. I have sometimes obtained a history of 
an abnormal attempt at coitus between boys and girls, the boys 
having suffered at the time from gonorrhea. Such cases are, how- 
ever, exceptional. The exciting cause is the gonoeoccus (Neisser) 
(Fig. 168). This micro-organism has been found in the discharges 
of all these cases, and cultivated (Koplik, Heiman). 



VUL VO VA GINITIS. 635 

Symptoms. — There is a thick, viscid, purulent, greenish or yel- 
lowish discharge from the vagina, which bathes the parts and dries 

in crusts on the labia. The opening of the urethra is reddened and 
swollen. There is a discharge from the urethra. Micturition is 
painful. In some cases there are slight swellings of the inguinal 
lymph-nodes. If the speculum which is used for the male urethra 
is introduced into the vagina (Tuttle's urethral speculum), it is seen 
that the purulent discharge is present in the folds of the mucous mem- 
brane of the vagina. The cervix uteri also contains a drop of pus. 
Thus the whole genital tract is involved. Some children complain 
of pain over the lower part of the abdomen. On examination, this 
is found to be pelvic, and is probably due to inflammatory reaction 
of the tissues about the uterus and vagina. 

Fig. 169. 




QonoCOOCi in vaginal discharge. Cover-glaSB spread. Photomicrograph. X 1000. 

Complications and Course. — The course of the disease is quite 
ted ion-, and may occupy eight weeks, three months, or more. The 
discharge may abate, only to return in its original severity. 

Peritonitis has in rare cases been reported as a complication of 
this form of vulvovaginitis. It may prove fatal. Ilunner and 
Harris recently reported a fatal case in a girl ten years of age. 
They collected .") other cases from the literature occurring in chil- 
dren. Pelvic peritonitis occurred in 2 of my cases with the usual 
Signs of pain and fever. Both cases made a good recovery. 

Hartley and I have reported cases of arthritis complicating vulvo- 
vaginitis in children. My ca.-es occurred in the first and second 
weeks of the disease. In one case, only one joint was affected ; in 
another, two. Both recovered without suppuration. 

Gonorrhoea! conjunctivitis may result from careless infection of 



636 DISEASES OF THE KIDNEYS. 

the eyes. I have had only 2 cases in which the patients complained 
of precordial pain. In neither were there active symptoms of endo- 
pericarditis, but there is no reason why it might not occur in chil- 
dren, as in adults. 

Sanger at one time traced a connection between sterility in later 
life and attacks of this disease in childhood. 

Treatment. — Prophylaxis is of great importance. A child 
affected with the disease should not be allowed to sleep with other 
children. The toilet appliances should not be used by other children. 
The parents should be carefully enlightened concerning the infec- 
tious nature of the affection and the great danger to the eyesight 
should infection of the eyes occur. The hands of the patient should 
be kept scrupulously clean. In institutions the patients should be 
strictly isolated. The vulva should be kept covered with a pad of 
absorbent gauze, and a diaper should be worn over this to prevent 
the discharge from soiling the clothes. In the acute stage, the 
vagina should be irrigated with a glass catheter or a Skene urethral 
catheter twice daily. The solution should be at a temperature of 
108° F. (42.2° C). The irrigating solutions should be either a 2 
per cent, solution of acetate of aluminum or a 1 : 2000 or a 1 : 500 
solution of nitrate of silver. If the silver or aluminum solution 
is irritating, a simple saturated solution of boric acid may be used. 
In the subacute stage the vagina is painted once daily with a 5 or 
10 per cent, solution of nitrate of silver. A Tuttle urethral specu- 
lum is used for the purpose. If the child is intractable, it is impos- 
sible to do this without the use of an anesthetic, which, however, 
seems scarcely justifiable. I have cured these cases with rest in 
bed and irrigations. I have tried the bougie treatment and the pro- 
targol and permanganate of potassium irrigations, but have found 
the treatment above described preferable. 

URETHRITIS IN MALE CHILDREN. 

Simple urethritis of the anterior portion of the urethra occurs in 
infants and young children. It is caused either by unnatural inter- 
ference with the parts or infection. It is not gonorrhoeal. The 
meatus is slightly red or the parts are agglutinated with dried pus. 
On pressure, a drop of pus exudes from the urethra. There is ardor 
urine, due to a slight fissuration of the meatus. The affection is 
easily cured by attention to cleanliness. An alkali, such as citrate of 
potassium, is given in very small doses, to alleviate the ardor urine. 

Gonorrhoea occurs in male infants and boys, and is the result of 
direct infection. The symptoms are much the same as in adults, 
except that, as a rule, there are no complications. Balanoposthitis 
and lymphadenitis may occur, also epididymitis, and rarely orchitis. 
Bokai reports cases of stricture. 



CYSTITIS. 637 

CYSTITIS. 

Cystitis is not very common in infants and children. Attention 
has recently been drawn to this affection by Escherich, who reported 
several cases of cystitis in young female children caused by coli 
bacteria. 

Etiology. — Barlow classifies cases of cystitis as follows ; 

(a) Chemical cases, caused by drugs. 

(6) Bacillogenous cases, caused by the tubercle bacillus, the Uro- 
bacillus liquefaciens, Bacillus coli communis, and the typhoid 
bacillus. 

(c) Coccogenous cases, caused by the gonococcus, staphylococcus, 
streptococcus, and various diplococci. 

Of all the micro-organisms mentioned, the Bacillus coli communis 
is the most frequent cause of cystitis (Melchior). 

The direct exciting causes of cystitis in children, as in the 
adult, are cold, catheterization, or calculi. It may follow urethritis, 
vulvitis, or may complicate the infectious diseases — scarlet fever, 
typhoid fever, and diphtheria. The changes in the bladder are, as 
in the adult, swelling and hyperemia of the mucous membrane. In 
chronic cases there are thickening of the ruga:, ulcerations, hemor- 
rhages, and the formation of false membrane (diphtheria). 

Symptoms. — The symptoms are deep-seated pelvic pain, a desire 
t«> pass urine, and, frequently, pain in urination. There may be 
slight fever. The urine is passed in small quantities, is cloudy, and 
contains flocculi and shreds of mucus and muco-pus. There is 
sometimes a sediment of creamy consistency. The urine may con- 
tain blood and pieces of false membrane (diphtheria). In tuber- 
culoid cases, there are tubercle bacilli in the urine. 

The cases may be acute, lasting only a week or two, or may be 
chronic, and last for months. In the variety caused by the coli 
bacteria (Kscherich) the urine is acid. It maybe acid in other 
acute form-. In the chronic tuberculous cases the urine may be 
alkaline and contain crystals of triple phosphates. The tendency 
in acute cases is toward recovery. Complications, such as pyelitis 
and peritonitis, may occur. 

Treatment. — If the symptoms arc acute, the child is put to bed, 
and the bladder washed out with a solution of creolin. Salol, grain 
ij (0.12), i- given three or four times daily. Urotropin, grain iij (0.18), 
is of great utility in the ammoniacal forms of cystitis. Alkaline 
water- (Vichy) are given freely and the bowels are kept open with 

alkaline -alt-. In convalescence an alkali, Buch as citrate of potas- 
sium, given in grain- v (<>..">) t. i. d., is beneficial. 

In chronic forms Baccbarin is sometimes the only drug that will 
give relief'. Grains ij (0.12) t. L d. may be administered to a child 
of 8LX year- with safety. 



638 DISEASES OF THE KIDNEYS. 

Leading Authorities Referred to in Chapter XIII. 

Abi, J. A. : "Floating Kidneys in Children," Jour. Amer. Med. Assoc, 1901. 
Baginsky, A. : "Ueber Pyelonephritis im Kindesalter," Deutsch. raed. Wochen., 
1897. 

Barlow: "Beitrg. zur setiol. and Cystitis," Arch. f. Dermat, 1893. 
Bockenheimer : Die Kongenitale Cysteninere, Dissert., Wurz., 1897. 
Comby, J. : " Floating Kidney," Trans. British Med. Assoc, 1898. 

"Lithiese chez les Enfants," VI. Verhandl. gesell. Kinderheilk. 

Churchill, F. S. : " Cyclical Albuminuria," Trans. Amer. Ped. Soc, vol. xiii. 
Cahen-Brach : "Urogenital Blennorrhea," IX. Verhandl. gesell. f. Kinder., 1891. 
Ddafield, F.: " Bright's Disease," Amer. Jour. Med. Sciences, 1891. 
Escherich, T. : "Ueber Cystitis bei Kinder," Mitt, aus der Verein der Aerzte, 

Steiermark, No. 5, 1894. 

Fordyce: "Cases of Urinary Infection with Bact. Coli " Jour. Cutan. and Gen.- 
Urin. Dis., 1893. 

Fretmann, B. G. : " Nephritis in Influenza," Trans. Amer. Ped. Soc, vol. xii. 

Hartley, F. : " Gonorrhceal Kheumatism," New York Med. Jour., 1887. 

Heiman, H : " Vulvo-vaginitis," New York Med. Kec, 1895-1898. 

Heineke: Maligne Nierengeschwulzte in Kindersalter, Dissert., Munchen, 1897. 

Hunner and Harris : Acute General Gonorrhceal Infection, Bull., Johns Hop- 
kins Hospital, vol. viii., No. 135. 

Jacobi, A. : " Primary Sarcoma of the Kidney," etc, Trans. Internat. Med. 
Cong., Copenhagen, 1884. 

"Floating Kidney" in Therapeutics of Infancy and Childhood. 

Koplik: "Urogenital Blennorrhea," Jour. Cutan. and Gen.-Urin. Dis., 1893. 

" Arthritis Complicating Vulvo-vaginitis," New York Med. Jour., 1890. 

Lewi, E.: "Sarcoma of the Kidney," Arch, of Ped., 1896. 

Melchior, M.: Cystitis u. urininfection, Berlin, 1897. 

Morse, J. L. : " Renal Complications of Acute Enteric Origin," Trans. Amer. 
Ped. Soc, vol. xi. 

Pott: Jahrb. f. Kinderheilk., 1883. 

Bachford, B. L. : " Albuminuria as a Litha?mic Manifestation," Trans. Amer. 
Ped. Soc, vol. x. 

Sanger: Die Tripperansteckung beim vveib, Leipzig, 1889. 

Senator : " Die Erkrank. der Nieren.," Nothnagel's Spec. Path, und Therap., 
Bd. xix. 



CHAPTER XIV. 

DISEASES OF THE SKIN. 

The skin of the infant is exceedingly delicate in structure. After 
birth there is a physiological condition of desquamation, as a result 
of which the skin is very sensitive to a traumatism which in older 
children would be considered slight. In the newly born infant, such 
is the delicacy of the structure of the skin that infection may occur 
when no lesion of continuity is apparent (cryptogenic). A rapid 
examination of the skin is the first step in making a full physical 
examination of an infant or child. The surface is first inspected 
from a distance, the color and the presence or absence of an eruption 
being noted. It is of the first importance to decide whether an 
eruption is acute or connected with constitutional taint (syphilis). 
An eczema may in a syphilitic infant have certain characteristic 
variations of color which will at once lead the examiner to suspect 
constitutional disease. A familiarity with acute eruptions (exan- 
thematie) is essential. These must be diagnosed or excluded before 
any treatment can be inaugurated. Forms of oedema must be differ- 
entiated from sclerema and myxoedema, and indurations of the skin 
from elevations. A papule may be elevated but not indurated. 
Since the skin of infants and children is exceedingly delicate, it will 
show indurations more distinctly than that of the adult. 

The Care of the Skin. — Stretching or harsh manipulation of the 
skin of infants will tear or traumatize it. Irritating soaps should 
not be used. The drying of the skin should be carried out gently. 
The skin in the groin and axilla should not be unduly stretched lest 
rhagades or fissures result. Tn powdering the skin, a fresh pledget 
of absorbent cotton should be used as a powder puff, and all the 
— of powder blown off, lest caking result. In some infants the 
wearing of flannel or wool next to the skin causes irritation and 
eruption- of different varieties. Such infants should wear a very 
fine cambric or linen garment next the skin, and over this the 
woollen shirt 

ECZEMA. 

Eczema i- a very common affection in infancy and childhood. 

Bome infant-, otherwise in apparent health, suffer at times from 
a very mild eczema of the face, which appears chiefly on the cheeks, 
but which may also be present on the chin, forehead, and ears. The 



640 DISEASES OF THE SKIN. 

infants do not seem to suffer much, except that they scratch the 
eruption. The eruption is local. It may improve without treat- 
ment, but if there are conditions of traumatism and infection, it will 
grow worse. It is rarely moist, but, if scratched, it will bleed, and 
fissures or ulcers with bloody crusts will form. 

Another form of eczema is pustular and vesicular. The skin of 
the face has a red, angry look. Here and there, patches of skin are 
covered with scabs ; in other areas the skin is moistened by a serous 
or seropurulent exudate. This eczema is usually also present on 
the hands and arms. If the malady has existed any length of time, 
there is considerable thickening of the skin of the hands. The head 
and scalp may be affected. 

Eczema is sometimes general. On the face, it is general and pus- 
tular ; on the body, there are both the squamous and the pustular forms 
with all the various gradations between. There are crusts, rhag- 
ades, and areas of superficial loss of tissue. 

The infants scratch and are uneasy and restless at night, but the 
general health is excellent and the appetite and digestion are good. 
The weight increases. If the eczema is general, the infants some- 
times become puny. They scratch the eruption, constantly causing 
the surface to bleed. The body is sometimes one raw, suppurating 
surface. The lymph-nodes connected with the affected surface are 
enlarged. Such enlargements should be differentiated from those of 
pyogenic origin. 

A very troublesome form of eczema is the impetiginous or pus- 
tular variety. The pustules burst and leave the surface covered with 
dried crusts of pus. This form may affect any part of the body. 
Of especial interest, and in a class apart, is the so-called impetigo 
faciei contagiosa. This is a contagious pustular eczema. It affects by 
predilection the upper lip and the alee nasi. The pustules break down 
and leave dry crusts of a golden-yellow color. The anterior nares 
may be blocked up by these crusts. This variety of impetigo may 
in children spread over the whole surface and the extremities. I 
have seen it affect several children in a family. There can be very 
little doubt as to the infectious and contagious nature of the malady. 
Eichstedt, Lustgarten, and others have, with cocci obtained from the 
pustules, succeeded in inoculating the malady on the human subject. 

Intertrigo (eczema intertrigo) or erythema intertrigo is one of the 
forms of erythema which develop by maceration into an eczema. 
Intertrigo is found in the folds of the neck, axilla, and groin, in 
well-nourished, rather obese infants. It is at first acute, but may 
become chronic. There is at first a slight redness of the folds of the 
skin (erythema). If through neglect the epidermis is allowed to macer- 
ate, excess of secretion results and the. collected secretions decompose ; 
the surfaces may become eroded, and ulcerations result. In some 
cases there are lineal ulcers in the groin. In others, the ulcers may 



ECZEMA. 641 

become coated with a pseudomembrane. In rare cases actual 
necrosis of tissue results. Some anaemic infants present a ten- 
dency to rhagade formation, not only in the groin, but also around 
the anus and lips. The intertrigo may have the color of copper, 
instead of the bright-red hue of an ordinary eczema. In such cases 
there is always a possibility that the intertrigo may be of syphilitic 
origin. If there is no great panniculus of i'at, and if with the inter- 
trigo there appear erythema and fissures between the toes, and glossi- 
ness of tlh' skin on the plantar surface of the feet, there are additional 
grounds for assuming that there is a syphilitic element. Intertrigo, 
like other skin eruptions, may be accompanied by enlargement of 
the lymph-nodes leading from the region affected. In obese infants, 
the umbilicus may also be the seat of eczema, which results from the 
accumulation and decomposition of secretions. 

Seborrhoea capillitii is an eruption on the scalp of infants and 
children, which is classified by Unna as a form of eczema. The scalp is 
covered with a coating of yellow or discolored sebum, which consists 
of fat, desquamated epithelium, and hair. If allowed to accumulate, 
it is sometimes of considerable thickness and may be detached from 
the scalp. It then leaves a slightly reddened surface, which may 
bleed. In a short time the scalp may become glossy, and a new 
layer of the fatty secretion may form. This process may continue 
until the second or third year. This seborrheic eczema has some- 
times a cheesy odor. 

Seborrhoea of the umbilicus has been mentioned. In infants and 
children there may also be seborrhoea of the prepuce. There are, 
in neglected cases, secretion and aphthous ulcerations of the folds 
between the glands and the prepuce and in the folds of the prepuce. 

Of great interest to the physician is a form of intertrigo or 
eczema found on the buttocks and between the nates of infants. It 
occurs in infants who are not kept dry and whose urine decomposes 
easily if the diapers are not changed frequently. This is a most 
troublesome form of eczema. The nates are at first red. the skin 
then becomes glossy and brittle, and there may be extensive desqua- 
mation of the surface. This form of eczema or intertrigo may dis- 
appear under treatment, only to return if precautions as to clean- 
liness and dryness are not observed. Some of the children suffer 
from enuresis, and contract the affection through maceration of the 
skin by the decomposed urine, or from unclean diapers. 

The etiology of eczema is still obscure. The conditions in 
infancy and childhood are favorable to the development of >l<in 
affection-. The delicacy of the skin, its constant exposure to 
dirt and to irritants of all kinds, and changes of temperature, are 
etiologically important. All the children of a family may suffer 
from eczema. In such instances, there is ;i real hereditary ten- 
dency to the disease. The parent- are sometimes similarly affected. 
u 



642 DISEASES OF THE SKIN. 

The influence of diet in causing eczema is not yet understood, but 
some authors are firmly convinced of the deleterious effects of 
certain articles of food. I have known urticaria to be caused by 
eating oatmeal and fruits, such as strawberries, and urticaria may 
be the beginning of eczema. In most cases eczema cannot be 
attributed to articles of diet. It is possible that in certain children 
the processes of metabolism are at fault. Though it has not been 
proved that all eczema is of an infectious character, there can be 
but little doubt that many forms are caused by the deleterious action 
of micro-organisms on the skin (Unna). In favor of this theory is 
the fact that in many parasitic skin affections eczema is an accom- 
panying condition. 

The treatment of eczema is exceedingly difficult. The external 
causes of irritation should be immediately removed. Attention to 
cleanliness is alone sometimes sufficient to cure an eczema. If 
woollen clothing is irritating to the skin, a substitute should be 
found and cotton or cambric should be worn underneath the wool. 

The diet should be regulated. This is not an easy task, since 
it is not known what articles of diet produce eczema. If the 
infant is at the breast, the diet of the wet-nurse and her daily habits 
should be regulated. Even when the nurse takes simple food, and 
the milk is flawless, the infant may suffer from eczema. If the 
nurse is addicted to the use of beer, or vegetables, such as asparagus, 
.the quality of the milk may be affected. The diet of a wet-nurse 
should not be changed more often than is necessary, else the secretion 
of milk may cease. If the wet-nurse has a rheumatic or gouty ten- 
dency, it is wise to change nurses. On the other hand, an infant may 
be overfed and excessively fat. In that case the intervals between 
nursing should be lengthened. To attempt to change the percentage 
of fat in the milk is not only of questionable utility, but is not always 
feasible. If the nurse is constipated, the bowels should be regulated, 
and she should take abundant exercise. Artifically fed infants are 
still more difficult to manage. If the infant is thriving, interference 
with the food percentage is not always clearly indicated. Artificially 
fed infants may also be overfed or the percentage of fat or proteids 
may be too high. There may, however, be eczema even when the 
composition of milk is proper for the infant, age and weight being 
taken into consideration. 

If there are acidity of the stomach, excessive flatus, constipation, 
or green stools, regulation of diet is of more practical utility. In 
such cases it may cause the eczema to diminish. If there is stomach 
acidity, an alkali (lime-water) should be added to the food. Consti- 
pation and flatulence should be remedied. If the infant passes urine 
loaded with urates to such an extent as to cause a red deposit on 
the diaper, small doses of bicarbonate of sodium should be adminis- 
tered and lime-water should be mixed with the food. 



ECZEMA. 643 

Changes of diet are helpful only in those forms of eczema which 
are either genera] or disseminated over different parts of the surface. 
Seborrheas and intertrigo are purely local affections, and are not 
influenced by changes of diet. 

Local treatment is chiefly relied upon to improve the condition 
of the skin. In the acute or subacute forms soothing applications 
arc utilized. The chronic forms arc irritated into a state of reaction, 
and then treated like acute eczema. The treatment of acute local 
eruptions, such as intertrigo, consists first in keeping the parts scru- 
pulously clean. After the bath the folds of the skin are mopped, 
dried carefully, and powdered, the excess of powder being blown 
off. This alone is sometimes sufficient to cure a slight intertrigo. 
Dusting-powders which contain carbolized preparations irritate the 
skin. A good powder has the following composition: 

H Zinci oxidi ,^iv(16.0). 

Amylum =ij (60.0).— M. 

Equal parts of zinc and starch powder make an equally good powder. 
These ingredients should be ground to an impalpable powder. In 
the severer forms of intertrigo, the parts should first be anointed with 
ointment having the following composition : 

R Resorcin gr. ij-iv (0.12-0.24 >. 

Adeps benzoinati 3J (30.0). 

M. — The lard should be washed. 

The ointment should be removed from the folds of the skin with 
a pledget of lint. The skin after being thus left in a slightly 
greasy state is powdered, the excess of powder being blown off. W 
there are lineal ulcers in the groin, they should be lightly touched 
once a day with a '2 per cent, solution of nitrate of silver, to promote 
granulation. The ointment should then be applied with a small 
piece of lint. 

In squamous eczema, which i- a red or pustular eczema of the face, 
scalp, and hands, the first question that arises is whether the patients 
should be bathed. An infant should be kept clean, and there is only 
one satisfactory method, and that is the bath. If there is eczema of 
any part of" the surface, the bath water may be liberally impregnated 
with bran. A gauze bag filled with a measure of bran i- put into 
the bath and the bag squeezed until the water become- turbid. If 
a minute quantity of* bicarbonate of sodium is added to a bath pre- 
pared in this way. the effect on general eczema is decidedly soothing. 
The -kin i- gently dried after the bath and powdered. If the whole 
trunk i- involved, it is best that the parts of the surface should be 
treated in succession. The face or an arm is covered with an oint- 
ment applied by means of a piece of lint, or the ointment is simply 
robbed on the -kin after the bath. It is not feasible to wrap the 
whole body in lint and ointment ; with certain drugs, such ;i> 



644 DISEASES OF THE SKIN. 

resorcin, absorption would occur. The ointments should be applied 
after the crusts and pustular accumulations have been removed. All 
ointments should be made up with washed benzoinated lard. Vaseline 
is very irritating to some forms of eczema. Of the emollient and 
soothing ointments, diachylon, zinc, and bismuth hold a leading 
place. A very good ointment for general use in rhagades and 
squamous eczema is the following, which is one of Kaposi's formulas : 

R Resin, benzoea pulv gj (4.0). 

_ Axung.porc ^v (150.0). 

Digere cola adde. 

Zinc, oxidat Jj (30.0). 

M. et. ft. unguentum. 

If made up properly, this is an excellent cosmetic ointment for use 
in dry eczema. If the skin is dry and thickened, a 1 per cent. 
/9-napthol applied twice daily will soften it. If this treatment proves 
irritating, a zinc ointment may be applied immediately afterward. 
In many cases of chronic eczema Lassar's paste is beneficial : 

R Acidisalicyl gr. xxx (2.0). 

Zinci oxidat. ") ._ -. , OAAX 

Amylum }••••< «« & (30.0). 

Vaselin ^jss (45.0). 

M. et ft. paste. 

The following ointment is also excellent : 

R Acidi salicylici gr. xv (1.0). 

Ung. zinci oxidi fij (60.0). — M. 

The tar salves and mixtures are useful in cases of chronic eczema 
in which there is little or no moisture. 

R 01. rusci 3j (4.0). 

Ungt. zinci ox gj (30.0). 

M. — For external use. 

or 

R 01. fagi £ijss (10.0). 

Glycerin 3j (4.0). 

Ung. diachylon ,^jss (45.0). 

Balsam. Peru mJ xxx (2.0).— M. 

In cases of red eczema of the face, the ointment is best applied 
on a mask made of lint. 

In that form of intertrigo which results from the irritation of 
urine, the condition of the diaper is frequently the chief source of 
trouble. It is often damp or too thin. As a result, whenever the 
infant passes urine, the diaper becomes saturated with it and decom- 
position takes place. A piece of absorbent gauze as large as the 
diaper should be placed next the skin, and renewed whenever it 
becomes moistened. The skin is dried and the ointment applied on 
the gauze. Intertrigo is quickly cured by this treatment. 



ERYTHEMA MULTIFORME. 645 

Treatment of Seborrhoea of the Scalp. 

The accumulated sebum is moistened with oil, or a piece of 
lint moistened with olive oil or any indifferent oil is applied at 
night. In the morning the crust of sebum \\ill have softened 
sufficiently to allow of its removal with green soap and water. 
Alter the parts are well cleaned, a salicylate^ ointment, 0.5 to 1 per 
cent., is applied daily. The ointment should be sparingly applied in 
order that it may not irritate the parts. Seborrhoea should be treated 
for some time after it is apparently cured, or it will return. In 
older children who have abundant hair, the seborrhoea accumulates 
at the roots and the seal]) has an odor. The head should be thor- 
oughly shampooed once a week ; after the shampoo, an exceedingly 
small quantity of cosmetic hair oil should be applied to the scalp 
once a day. 

ERYTHEMA MULTIFORME. 

(Erythema Nodosum; Erythema Exudativian.) 

Erythema exudativum is divided into two forms. The acute 
form includes erythema multiforme and nodosum, and is an acute 
infections disease (Lewin). The exudative form occurs frequently 
in infant- and children. Of 40 of my cases, 10 were under two 
year- of age. The form of erythema known as erythema nodosum 
begins with general malaise and sometimes with fever, which may 
be quite high. There is pain in the joints and over the areas affected. 
These areas are raised and are purple or bluish : the skin is tense and 
the parts affected are very painful. The nodes vary in size. They 
first appear chiefly on the extensor surface of the tibia?. The 
extremity sometimes looks as if it had been beaten. This form 
of erythema is perhaps allied to hemorrhagic diseases, such as 
peliosis. In a case of peliosis rhenmatiea which I saw recently 
there were erythematous and painful nodules on the hands. Anti- 
toxin may cause exudative erythema. A- is well known, such toxic 
infection also involves the joints. The symptoms are lexer, pain in 
the joints, and extensive erythema nodosum. I have seen such a 
case in a subject, who had received an immunizing injection. Within 
BUS hours, the leg-, knees, and thighs were swollen and the seat of 
this peculiar erythema. 

French writers speak of the frequency of cardiac disease in 
erythema nodosum, and of its relationship to rheumatism. I have 
carefully studied 40 cases for signs of cardiac disease, and could 
find only •*) cases with systolic murmur at the apex. I have recently 
seen '1 others. In my opinion, true endocarditis is not a very com- 
mon complication of erythema nodosum. In only one case did the 



646 DISEASES OF THE SKIN. 

murmurs appear to be serious. The disease lasts only a few days, 
but there may be relapses. 

The second form of chronic erythema resembles the acute form. 
The nodules are flat and deep, and are not raised much above the 
surface. They appear chiefly on the lower extremities of badly nour- 
ished children. They are less painful than in the acute form. After 
a time they disappear leaving no sign of their presence. 

Treatment. — Cases of erythema of the acute form are treated 
with sodium salicylate and a diet of milk at first, fruit-juices and beef- 
juice being given later, and local applications of oil of wintergreen 
to the painful areas. 

FURUNCULOSIS. 

(Folliculitis Abscedens or Perifolliculitis Abscedens. — Escheeich.) 

This affection of the skin is very common in infancy and child- 
hood, and occurs chiefly in badly nourished, marantic babies, who 
suffer from gastro-enteric and pulmonary infections. The disease is 
due to an invasion of the deeper layers of the skin by staphylococci. 
These have been found in the pus and in the sweat and sebaceous 
glands of the skin (Escherich). In the mild forms of furunculosis 
there are one, two, or more furuncles on the forehead, scalp, occiput, 
and neck. Sometimes the furuncles are large and the skin is riddled 
with them, but as a rule they do not communicate with one another. 
In aggravated cases, furuncular abscesses occur on the trunk and on 
the upper and lower extremities. When the furuncles or boils 
become very numerous, they play a leading role. Many children in 
institutions succumb to this affection. The condition closely resem- 
bles a form of sepsis. 

The treatment of these cases is simple. I have administered 
alkalies, such as bicarbonate of sodium, internally. The effect on 
the general process is excellent. I have also given sulphide of cal- 
cium in grain J doses (0.03) with good effect. The infant is 
bathed in bran daily. Too many of the abscesses should not be 
opened at once, and they should not be opened until they point and 
the skin over them becomes reddened. If they are opened earlier, 
the results are not so good. After the abscesses are opened, the pus 
is expressed and a moist dressing applied. The abscesses heal easily. 
As in other septic affections, the patients should be stimulated and 
carefully fed. Small furuncles appearing only on the face need not 
be opened. The application of a 2 per cent, salicylated ointment 
twice daily softens the pustules and causes the contents to be dis- 
charged. 



DERMATITIS EXFOLIATIVA. 647 



SUDAMINA. 



{Miliaria Alba; Miliaria Rubra.) 

Sudamina is an affection occurring in infants and children during 
very warm weather. In the form called miliaria alba the epidermis 
at the openings of the sweat-glands is raised by a minute serous exu- 
date and small vesicles arc formed. There is no inflammation of 
the -kin. In a second form, the same process takes place, with the 
presence of a minute focus of inflammation and redness at the opening 
of the glands. Some of the vesicles are pustular. There are also 
numerous papules of eczema. There is a slight infection of the skin 
about the opening of the sweat-glands. Both these conditions 
are irritating, but in no way serious. The skin should be kept 
scrupulously clean and dried with powder. Woollen fabrics should 
not be worn next the skin. If the condition becomes severe, 
bran baths and a bland zinc or diachylon ointment should be 
used. Sudamina of both varieties are met with in scarlet fever 
dermatitis. 

DERMATITIS EXFOLIATIVA. 

(RlTTER VON RlTTERSHAlX.) 

This affection is peculiar to the newborn infant. Ritter in 1878 
described an epidemic. In 1895, Escherich published an account 
of a small local outbreak in Gratz. 

Nature and Etiology. — It was first suspected by Ritter to be 
one of the septic infections of the newly born infant. His view has 
lately been supported by Escherich. 

Occurrence and Symptoms. — The disease appears from a few 
day- to two week- after birth. It usually occurs in poorly nourished 
infant-, but may affect apparently healthy infants of normal weight. 
Boys are more frequently affected than girls. The affection is pre- 
ceded by the appearance of a diffusely red erythematous or (lark 
swelling of the general surface. The skin is thickened, soft, mac- 
erated, and velvety to the touch. The epidermis can be moved on 
the corium beneath. The pressure of the clothing or bedclothes may 
also produce this effect. Minute vesicles appear, and coalesce to 
form larger vesicles or bullae. Vesicles or bullae of large size which 
may be either partly filled with serum or empty are formed. They 
are never tense, and finally open or tear, leaving the red moist corium 
exposed. The surface of the body has a beefy-red color, and is 
covered here and there with patches of dry, adherent epidermis ; in 
other area-, thecorium i- exposed. There are rhagadesat the angles 
of the month and on the trunk. 'I'he upper extremities become 
affected later than the lower one-. Whole areas of the trunk and 
body are denuded of epidermis. After the vesicles burst and leave 



648 DISEASES OF THE SKIN. 

the corium exposed, the epidermal layer of the skin is still adherent 
in places, while the desquamated skin is rolled up into cord-like 
masses and hangs loosely exposed. If recovery takes place, the 
corium becomes covered with a delicate epidermis, which gradually 
assumes the normal pinkish-white hue. Some cases may run an 
afebrile, others, a febrile course. 

Course and Prognosis. — A few of the cases recover. Ritter 
lost 50 per cent, of his cases, and Escherich 90 per cent. The 
infants may die from the sixth to the tenth day or after the third 
week, when much of the skin has undergone retrograde changes. 
The cases may show umbilical infection or lobular pneumonia point- 
ing to the septic nature of the disease. 

Treatment. — The infants are kept warm by artificial means, 
such as warming bottles or an incubator. They are not bathed. The 
skin is protected by the application of bland salves or gauze moist- 
ened with a mixture of linseed oil and lime-water (Escherich). 
Some physicians add a small quantity of salicylic acid to the salves. 
As soon as the skin has become dry, Lassar's paste and powdered 
zinc are applied. 



CONGENITAL ICHTHYOSIS. 

, i ■ . ( Cutis Sebacea. ) 

Ballantyne gives an exhaustive description of this affection, which 
is really a perpetuation of a foetal condition into post-natal life. 
The foetal skin has a tendency to seborrhoea. This is apparent after 
birth, and is evident during infancy as seborrhoea of the scalp. The 
seborrhoea may affect different parts of the body and may form thin 
shining scales on the surface of the skin. There may be secondary 
eczema. The mild forms may, with ordinary cleanliness and the appli- 
cation of bland salves, disappear a few weeks after birth. The form 
described by Hebra and Kaposi as ichthyosis congenita is an extreme 
example of the tendency of the foetal skin to the formation of sebum 
or vernix. The increased secretion continues after birth. The in- 
fant appears to be covered with a horny mass which almost envelops 
it. This parchment-like covering is absent at the mouth, eyes, anus, 
and on the scalp. The surface is firm and of a yellow or brownish- 
red tint (Escherich). The hardness and brittleness of the skin 
render motion painful. The infant is enclosed as if in case-armor. 
The face has a mask-like expression. The skin is broken in places, 
especially at the joints. At these fissures the true skin is seen. At 
the broken spots, the sebum is seen to be composed of lamellae, from 
the posterior aspect of which project warty excrescences corresponding 
to the lanugo and openings of the sebaceous glands. These may be 
removed from the skin. If the infant lives, the layers of sebum are 



PEMPHIGUS NEONATORUM. G49 

thrown off gradually, and the skin is left with a general seborrhcea 

of the ordinary type. Escherich predicts a favorable course in mosl 
of these cases, but some die shortly after birth. Pathologically there 
is a great thickening of the rete Malpighii ; the corium shows no 
changes : the sebaceous glands are atrophied or the seat of fatty 
degeneration ; the sudoriparous glands are normal. After the layers 
of horny sebum have peeled off, the skin underneath appears pink or 
red or shining, and is covered with seborrhceal scales. 

The treatment consists in the application of emollients and in 
washing the skin daily or bathing the infant in permanganate of 
potassium (grains xv (1.0) to the hath water). Salicylic and boric 
ointments are applied after the baths. 



PEMPHIGUS NEONATORUM. 

Pemphigus neonatorum is a contagious infectious disease of the 
skin occurring in the newborn infant. It has also been observed 
later in infancy. It usually appears at the end of the first or second 
week, and affects the whole surface, except the palms of the hands 
and the soles of the feet. There appear on the surface of the trunk 
and extremities small and large vesicles containing cloudy serum. 
These burst and leave a round patch of skin, which dries and is 
covered with yellowish scales. The vesicles may attain the size of 
bulla?. They may be discrete or involve the whole body, so that 
the surface is after a time denuded of the epithelial layer. The 
disease may in the beginning be confounded with dermatitis exfoli- 
ativa. The vesicles may appear in crops ; the recurrences may 
extend over a period of from two to four weeks. 

There are two form-, in one of which the disease is mild; in the 
other, it runs a malignant course, and from the outset large areas of 
skin are denuded of epithelium by the bursting of enormous bullae. 
The infant- pass into an asthenic condition, refuse nourishment, and 
die in a few days. Both form- appear in epidemics. The disease 
occur- sporadically. The essentia] cause is still obscure. Strelitz, 
Demme, Almquist, and Escherich have isolated a white staphylo- 
coccus from tin- serum of the vesicles. Its role as an etiological 
factor i- not as yet understood. Escherich is inclined to class this 
form of pemphigus with other infectious skin diseases, -neb a- the 
impetigo of Wilson or Bockhart, and folliculitis abscedens, in which 
certain conditions favor serous infiltration of the horny layer of the 
skin and extensive desquamation from the corium. He believes the 
exciting cause t<» be the pus cocci found in other forms of impetigo. 
Escherich has suggested the ose of the name " Cmpetigo Bullosa 
Neonatorum or Infantum" for tin- affection. 

The prognosis i- favorable if the process confines itself t<» the 



650 DISEASES OF THE SKIN. 

superficial layers of the skin. If the deeper layers are attacked, 
abscesses and general sepsis result. 

Treatment. — Escherich recommends that the affected parts 
be washed with soap and water, and dressed with a 2 per cent, 
ointment of white precipitate. Baths are not given. Those who are 
interested in the epidemiological aspect of this disease will find the 
monograph of Bichter exhaustive. 

Leading Authorities Keferred to in Chapter XIV. 

Ballantyne, J. W. : Antenatal Pathology and Hygiene, Edin., 1902. 

Escherich, T. : " Diseases of the Skin in the Newly Born," Pediatrics, 1897. 

"Zur setiol. der Multinlan Abcesse. Folliculitis Abscedens," Munch. 

med. Woch., 1886, Nos. 51 and 52/ 

Richter, Paul: Ueber Pemphigus Neonatorum, Berlin, 1902. 

Unna, P. G. : Article " Eczem.," in Handbuch der Hautkrankheiten, Mracek, 
1902. 



INDEX OF AUTHORS. 



ABT, 614, 638 I 

Achard, 129, 596,606 
Adams, 445, 446 
Afanasjew, 201 
Ahlfeld, 73, 84 
Alix, 47, 84 
Almquist, 457, 649 
Amber?, 334, 355 
Anton, 276 
Antonelli, "273 
Ausset, 462, 467, 588 

BABES, 37, 95, 289, 290, 
304, 392, 5S4, 605 

Babinski, 257 

Backhaus, oS, 84 

Bacon, 601 

Baginsky, 107, 109, 113, 
145, 154, 206, 216, 235, 
317, 326, 392, 459, 479, 
-540 

Ballantyne, 648, 650 

Banti, 392 

Barfurth, 48 

Barker, 113 

Barlow, 446, 565. 593, 

Barlow (Ger.), 637, 638 

Bartels, 144,152,156, 021 

Barthez, 239, 2.". 1. 610 

Bauer, 458 

Baumgarten, 241, 24"> 

Baumler, 555 

Beck, 108, 355 

Bednar, 277,436, 

Bearing. 235. 276 

Bein, 197 

Benecke, ~>~>~> 

i .liin, 579, 587 

Berkeley, 491 

Bemabei, 282 

Bernard, 320,564 

Bernheim, 28^ . 469 

Benin, 88 

Besnii 

Biedert, 66, 7:;. 355 

Billard, 158 

Billing. 383 

Birch-Hirechfeld, 236,243 

Bishop, 304 

Blackader. 212. 276, 304 

Blanchard, 552 

Blauberg, 309 

Blnmenfeld, 596, 605 



Blumer, 276 
Bockenheimer, 638 
Bohm, 292, 588 
Bokai, 295, 304, 017 
Boltee, 532 
Bonnard-Favre, 432 
Booker, 208, 316, 328, 355, 

432 
Bordoni-UfTreduzzi, 191 
Borger, 355 
Botkin, 610 
Bouchard, 548 
Bouchut, 624 
Bourdillot, 154 
Boussage, 235 
Bovaird, 242 
Bowditch, 414, 432 
Bretonneau, 36, 206 
Brever, 154 
Brieger, 108 
Briquet, 476 
Budin, 54, 55, 84 
Bugge, 243 
Bollinger, 241 
Biirkel, 593 

riAHEN-BBACH, 634, 

\J 638 

Caille, 240, 499 

Oamerer, 53, 55, 66, 7:'., 84, 

615 
Oantani, 42, 84 
Carr, 593 

Carstanjen, 572, 593 
Celli, 276, 330 
( lesaris-Demel, 491 
Cestan, 432 
Chapin, 84 521 
( 'harcot, 523, 545, 555 

Chaterinkoff, 311 
Chauffard, 610 
Cheadle, 588, 593 

Churchill. I 

Chvostek, 17-".. 181, 548 

Clark, 479 
Cohnheim, 102 
Comby, 614, 
Conrad, v 1 
Contaret 305 
Cornet, 236,239, 276 
(on.il. 392 
( btton, 552, 555 
( "oult, 551 



Councilman, 191, 208,219 

270, 409, 620 
Counnount, 606 
Crandall, 490, 588 
Cruse, 111 
Cutter, 289 
Czapelewski, 201 
Czernv, 97, 305, 308, 355 

432', 621 

DANA, 507 
Decaisne, 60 
Peichler, 201 
Delafield, 191, 392,443, 459, 
500, 501, 619, 620, 638. 
I Demnie, 251, 568, 611, 
613, 618, 649 
Dench, 604, 606 
Dennig, 252, 258, 276 
D'Espine, 165 
Doane, 71, 84 
Doderlein, 627 
Doehle, 35 
Dolega, 564 
Donkin, 551 
Doremus, 554 
I )i eschfeld, 446 
Drewitz, 305 
Duchenne, 518 
Duel, 127, 270, 606 

EBEN, 241 
Eberle, 268 

Ebert, 499 

Ebstein, 553, 628 

Edwards, 467,613 

Ehrlich, 57."., 578, 593,618 

Eichstedt, 640 

Elsiisscr, 184 

Emmerich, 95 

Emminghaus, 111. 142 

Eppinger, !<>•_> 

Epstein, 17, 36, 39, 84, 95, 
102, 107, 200, 277. 304, 
335. 355, 483, 55:;. 575 

Erh, 170, 181, 518 

Ernst, 159 

Eross, 18,84 

Escherich, 18, 69, 7:;. 109, 
206, 235, 316, 329, 179, 
184, 532, 541, 581, 593, 
637, 646 

Ewing, 383 

651 



652 



INDEX OF AUTHORS. 



FEEE, 18, 31 
Fehling, 28, 84 
Felsenthal, 320, 572 
Fielder, 276 
Filatow, 147, 355 
Finger, 266 
Finkelstein, 314 
Finkler, 432 
Fischl, 95, 97, 117, 206, 

272, 276, 432, 479, 532, 

575, 621 
Fleischman, 305, 311, 467, 

536 
Fletcher-Beach, 560 
Flexner, 210, 457 
Flindt, 147 
Foa, 191 
Folger, 613 
Folwarczny, 613 
Forcheimer, 142, 282, 304, 

574 
Fordyce, 638 
Forster, 588 
Foster, 441 

Fournier, 84, 262, 276 
Frankel, 135, 243, 371, 634 
Freeman, 70, 638 
Frendenberg, 135 
Frerichs, 552 
Freymuth, 290, 304 
Friedeleben, 567, 568 
Friedlander, 132, 282 
Friedreich, 458 
Frosch, 392 
Fruhwald, 304 
Furbringer, 132, 154, 620 
Fiirst, 588 

GAESLEE,276, 606 
Gaillard, 377 
Ganghofner, 479, 484 
Gamier, 242 
Gartner, 95 
Gee, 484, 499, 588, 593 
Geissler, 593 
Genrich, 104 
Gerhardt, 133, 142, 611 
Gerster, 344 
Gibney, 597, 632 
Gibson, 355 
Goodhardt, 567 
Gowers, 32, 476, 480, 487, 

489,492,508,509,519,522 
Grandidier, 102 
Grawitz, 567 
Gregor, 356 
Greves, 613 
Griffith, 140, 146, 298, 304, 

519, 532 
Guillet, 629 
Gull, 615 
Gultmann, 467 
Gundling, 53 



Gundobin, 571 
Guppen, 571 
Gutmann, 548 

HADDEN, 499 
Hahner, 73 
Hammarsten, 65 
Hammersley, 572 
Hansemann, 555 
Harbitz, 442, 443 
Harris, 334, 635 
Hartigan, 108 
Hartley, 551, 635, 638 
Hather, 135 
Hayem, 570, 593 
Hecker, 104 
Heermann, 599, 601 
Heim, 140 
Heinecke, 638 
Heirman, 454, 638 
Heiter, 458 
Heller, 267 
Hennig, 116, 610 
Henoch, 144, 244, 387, 484, 

485, 486, 489, 492, 494, 

545, 587, 593, 607, 611, 

616, 623, 624 
Henschen, 467 
Hensel, 201 
Herz, 48, 56, 84 
Herzfeld, 251, 276 
Heubner, 135-136, 191, 

235, 306, 309, 315, 356, 

471, 545, 552 
v. Heukelom, 99 
Hildebrand, 140 
Hirsch, 194, 317, 504 
Hirschsprung, 552, 590 
His, 564 
Hlava, 548 
Hochsinger, 266, 267, 276, 

441, 467, 455, 482, 483 
Hock, 572, 593 
Hodenpyle, 300 
Hoff, 618 
Hoffman, 207, 372, 520, 

574 
Hofmeier, 111 
Hofmokl, 116, 412 
Holt, 305, 375, 432, 588, 

624 
Home, 144 

Hoppe-Seyler, 58, 65, 618 
Horbaczewski, 619 
Horsley, 564, 565 
Houl, 243 
Hudelo, 267 
Hunner, 635 

Hutchinson, 238, 263,266 
Huttenbrenner, 99 

TMMERMANN, 583 
1 Ireland, 532 



TABOULAY, 606 
V Jaccoud, 235 
Jackson, 491 
Jackson, Hughlings, 472 
Jacobi, 78, 239, 448, 467, 

490, 541, 544, 548, 551,. 

565,566, 567, 593, 614, 

628, 638 
Jager, 191, 610, 613 
Jahni, 243 

von Jaksch, 375, 557, 593 
Japha, 579, 593 
Jeandin, 165 
Jenner, 163 
Judassohn, 282 
Jurgensen, 119, 131, 144, 

152, 376, 385, 432, 494 

KAREWSKI, 295 
Karowin, 305 
Kartullis, 329 
Kassowitz, 472, 482, 484, 

540, 541, 544, 545, 555 
Kast, 289 
Keating, 467 
Kee, 115 
Keen, 503 
Kehrer, 111, 284 
Keller, 78, 79, 84, 321, 

375 
Kelsch, 578 
Kemp, 42, 43, 139, 625 
Kessler, 371 
Kingdon, 504 
Kirmisson, 530, 531, 532 
Kissel, 610 
Kitasato, 185 
Kjelberg, 320 
Klebs, 102, 135, 206 
Klemperer, 443 
Kling, 104 
Kmerien, 282 
Knapp, 602 
Knoepfelmacher, 65, 74, 

84 
Koch, 594 
Kocher, 564 
Kockel, 243 
Kohts, 272 
Kolaczek, 99 
Kolb, 584 
Kolisko, 208 
Konig, 58, 60 
Korner, 606 
Kossel, 317, 599, 619 
Kundrat, 104 
Kurloff, 201 
Kussmaul, 473 

LABI, 89 
Lachman, 628 
Lachs, 47 
Landau, 104,117 



INDEX OF A UTHORS. 



653 



Landois, 437 

Landouzy, 243, 377, 470, 

610 
Landry. 517 
Lannelongue, 99, 129, 243, 

596, 606 
Lazarus, 446 
Lebreton, 584 
Lehman, 243 
Leichtenstern, 191, 571 
I a- jars, 027 
Lenhartz, 36, 468 
Leo, 306 
Leonhardt, 241 
Leube, 385, 616 
Leuckart, 356 
Levi. 89 
Levy, -'> v: ' 

Lewi, 499, 553, 638 
Lewin,430 
Leyden, 548 
Libman, 317,490 
Lichtenstein, 563 
Lichtheim, 372 
Lillientlud. 344 
Limbeck. 504 
Litten, 35, 131, 132, 
little, 509 

Lladd. 58, 69, 84, 594 
Lloyd, 572 
Loeffler, 206 
Lombard, 197 
Loos, 482, 484, 624 
Losch, 334 
Ldschner, 613 
Lote. 135 
Lowit, 578 
Luschka, 567 
Lustgarten, 640 
Luzzatto, 201 
Luzet, 575 

MCDONALD, 56, -I 
Macewen, 276, 532 
Maggiora, •">•* , > , ' 
Magnus, 199 
Mallory, 208, 276 
Manges, 545 
Mann. 613 

Marfan. 242, 316,356 
Marie, 520 
Marotte, 304 
Marshal] Hall. 92 
Mattie, 276 
Matterstock, 344 

Mavd). 131 

Mayer, 219 

Mavr, 1 I 1 

McBurney, 3 15 
McCrae, 579 
McNntt, 509,515, 
Meckel, 99 
Mi-din. 252, 520 



Meigs, 84 

Meinert, 574 

Melchior, 637, 638 

Meltzer, 315 

Mendelsohn, 107 

Menetrier, 235 

Merekel, 613 

Mettenheimer, 613 

Meyer, W., 315 

Michaelis, 197 

Michel, 309 

Miller, 548, '^'\ 579 

Minkowski, 111 

Mi.jiiel, 69 

Moebius, 21 

Moller. 588 

Moncorvo, 551, 555 

Monti. 36, 68, 69, 109,204, 

•206, -260, 536, 552 
Morse, 31, 276, 320, 356, 

542. 555. 579, 5D4, 621, 

638 
Moschowitz, 117 
Moser, 432. 470 
Mosler, 578 
Mr&cek, 273 
Muller, 442 

Murchison, 119,608,611 
Mussy, Sit 

\TAEGELI,589 

11 Nakarai, 243 

Nansen. 589 
Naunyn, 111, 191 
Nauwerck, 589 
Neisser, 110, 634 
Xetter. 191, 27(5, 377, 386, 

4:52. 442. 588, 599 
Neumann, 95, 266, 392, 

432, 613 
Niclot, 304 
Xieoll, 315 
Nieden, 632 
v. Noorden, 580 
Northrup, 150. 201, 216. 

235, 212. 211. 392, 432, 

594 
Nothnagel, 251, 344 



Nottingham, 151 

0'DWYER, 39 
Ogle, 191 

Oil .an. 308 

Ord. 564 

Osier, 119, 258, 366, 190, 

491,511, 532, 515. 560, 

568, 594 
Otto, 670 

P\< K AIM), 302, 11-;. 
167, 547 
Paltanf, 208 
Papiewski, 109 



Park, 235 

Parrot, 2S4, 285, 21)1, 325, 

566, 507,615. 621 
Pascaud, 117 
Pasteur, 70, 520 
Pautz, 30S 

Paw, 552 
lVarce, 200, 276 
Perutz, 377 
Peterson, 172 
Petruschky, 200, 304 
Pfaundler, 305, 314, 356, 

468, 532 
Pfeiffer, 135, 185 
Polyniere, 392 
Ponfick, 598, 500, 618 
Pott, 438, 486, 503, 567, 638 
Pratt, 432 

Preobrachensky, 135 
Preyer, 84 
Price, 71, 84 
Pi i i rhard, 356 
Prudden, 05, 150,216,235, 

3,02, 432 
Putnam, 521 
Pye-Smith, 401 

QCESINER, 302 
Queyrat, 24:', 
Quincke, 468 

RA(TIFOKI), 581, 638 
Rankin, 136 
Rasch, 50S 
Rauchfuss, 190, 442 
Bees, 284 

Kehn. 148, 588, 613 
Reiner, 251 
Renaud, 276 
Reymond, 432 
Ribbert, 268 
Richter, 650 
Rieken, 468 
Rilliet, 107. 230,251 
Rindlleisch, 245 
Ritchie, 315 
Ritter, 282, 305, 647 
Riverdin, 56 1 
Roberts, 552, 630 
Robin, 615 
Roger, 212 
Rohrer, 628 
Rokitansky, 139 
Poloir. 243 
Romberg. 131 
Rosenstein, 628 
Rosinski, 289,304 
Rotch, 101. 305, 532, 571. 

594, oor, 
Ponx. 2D7. 235, 578, 620 
Rubner, 309 
Runge, 101, 102, 104, H>7, 

111, 117 



654 



INDEX OF AUTHORS. 



Riitimeyer, 519 
Kyan, 304 

n ACHS, 488, 491, 504 
JO Sahli, 567, 568 
Sanger, 187, 532, 638 
Sansom, 440, 467 
Santulus, 291 
Schamshin, 457 
Schamtyr, 282 
Schapringer, 21 
Schiff, 570, 594 
Schlessinger, 572, 593, 613 
Schlichter, 59, 84 
Schlossberger, 619 
Schmidt, 276 

Schmorl, 208, 243, 589, 594 
Schoedel, 589, 594 
de Schweinitz, 490 
See, 459, 466, 491 
Seeligmiiller, 518 
Seidl, 261 
Seitz, 206 
Senator, 613, 616,625,627, 

628, 638 
Sidney, 207 
Siegfried, 59 
Silbermann, 111 
Simmonds, 412 
Sinkler, 520 
Slawyk, 147, 276, 470 
Smith, J. L., 134, 503, 565, 

588 
Snow, 343, 533 
Soldner, 58 
Soltman, 109, 467 
Somma, 272 
Sonntag, 241 
Sorensen, 136, 570 
Soxhlet, 63 
Spiegelberg, 104 
Stadelmann, 111 
Starck, 430 
Starr, L., 68 
Starr, M. A., 261, 490, 492, 

493, 495 
Steffen, 251, 252, 366, 432, 

434, 442, 447, 458, 459, 

460, 608 



Steiner, 476, 478, 491, 


588, 1 


Vigier, 69 




614 




Vincent, 304 




Stengel, 432, 594 




Virchow, 209. 529, 


544, 


Steudener, 568 




567, 574, 577 




Stewart, 614 




Vogel, 308, 615 




Still, 242 




Voinitch, 461 




Stohr, 300 




Voit, 204 




Stork, 486 




Voorhees, 117 




Strauss, 579 








Strelitz, 107, 392, 649 




WALSH, 290, 304, 
VV Walshe, 467 


463 


Striimpel, 509, 520 






Symington, 358, 435 




Watson, 633 




Szemetzchenko, 201 




Wegner, 544 




Szontagh, 65 




Weichselbaum, 191, 
443, 446 


386, 


rilALOMAN, 215 
1 Tardieu, 458 1 




Weigelin, 73 






Weigert, 102, 235, 243, 245 


Tay, Warren, 504 




Weil, 385, 467, 545, 


555, 


Tenner, 473 




610, 613 




Terrier, 432 




Weiss, 610 




Thomas, 140, 152, 


160, 


Welch, 36, 371, 443, 457 


492 




Welt, 581 




Thomson, 314, 356, 


.499, 


Wentworth, 470, 575, 


594 


532, 565, 566, 594 




Werhofsky, 457 




Thursfield, 276 




West, J. P., 189, 190 


240, 


Tizzoni, 548, 584 




276, 567 




Todten, 613 




West (Eng.), 588 




Townsend, 490, 565 




White, 58, 69, 84, 432 


, 594 


Treves, 339, 340, 356 




Whitman, 540 




Triesethau, 567, 594 




Widerhofer, 613 




Trousseau, 475, 479, 486 


Widowitz, 571 




Tschamer, 135 




Wilke, 611 
Williams, 18 




TTFFELMAN, 309 
U Ullman, 467 




Winckel, 95, 102, 107 






Wohlman, 306 




Ultzmann, 615 




Wolff, 219 




Unger, 251 




Woronichin, 291, 304 




Unna, 641, 642, 650 




Wright, 208, 276 
Wrobelewski, 65, 84 




\7ALLEE, 344, 356 








V VanArsdale, 101, 129, 


yEESIN, 207 




135, 557, 558, 


594, 




596, 606 








Van Dusch, 634 




7AMB0L0VICI, 
Lk 290, 304 


289, 


VanPanum, 144 






Van Puteren, 306 




Zeissl, 266 




Variot, 484 




Ziegler, 392, 443, 459 




Veillard, 578 




Zuppert, 520, 521 




Vierordt,47,84, 433,440,467 


1 Zweifel, 555 





INDEX OF SUBJECTS. 



ABDOMEN, examination of, 25 
inspection of, 25 
palpation of, 26 
retracted, 26 
shape of, 25 
Abdominal distention, idiopathic, 26 

typhus. See Typhoid fever. 
Abscess of liver, 612 

periarticular, in scarlet fever, 130 
Accessory sinuses, affection of, in diph- 
theria,' 219 
Achondroplasia, 565 
Acorn-cocoa, 80 

Adenitis, acute, diagnosis of, 558 
in diphtheria, 221 
etiology of, 557 
symptoms of, 557 
treatment of, 558 
Adenoid vegetations. 298 

contraindication to operation, 

299 
diagnosis of, 299 
Adhesions, pleural, in empyema, 429 
Agenesis corticalis, 509 
Albumin water, 80 
Albuminuria, cyclic, 615 

postural, 615 
Amaurosis in scarlet fever, 130 
Amaurotic idiocy. Set Idiocy, amaurotic. 

idiots, head in, 20 
Amorphism, dental, 281 
Amygdalitis, acute follicular, 300 
diagnosis of, 302 
duration of, 302 
etiology of, 300 

lymph-nod*-, in. 302 

prognosis of, 302 
temperature in, 302 

treatment of, .">02 
Amyloid degeneration in bronchiectasis, 

:;7:; 
Anaemia, 572 

blood in, 574 
congenital, 572 

■itial. 572 

Lymphatic, r <~ r > 
in malaria, 572 
pernicious, 

characters of, 587 
primary, 572 
pseudoleuksemic, 575 

the blood in, 576 

course of. 576 



Anaemia, pseudoleuksemic, etiology of, 575 
liver in, 575, 609 
morbid anatomy of, 575 
occurrence of, 575 
spleen in, 576 
symptoms of, 575 
treatment of, 576 
in scarlet fever, 132 
secondary, 573 

>ymptoms of, 573 
simple, 573 

blood in, 574 
in syphilis, 572 
in tuberculosis, 572 
von Jaksch's, 575 
Anaemic murmurs, 574 
Anasarca in nephritis, 622 
Angina, cardiac, in aortic disease, 453 
Ani, prolapsus, 349 

etiology of, 349 
svmptoms of, 349 
treatment of, 349 
Antipyresis, 34 
Antitoxin. See Diphtheria. 
Antitoxins in mother's milk, 17 
Anus, fissure of, 350 

diagnosis of, 350 
symptoms of, 350 
treatment of, 350 
spasm of, 350 
Aphasia in pertussis, 204 
in scarlet fever, 131 
Aphthae, Bednar's, 283 

treatment of, 284 
in diphtheria, 221 
Apnoea, respiratory, in retropharyngeal 

abscess, 297 
Appendicitis, 344 

catarrhal form, 344 
chronic, 348 
course of, 345 
diagnosis of, 345 
fever in, 347 
forms of, 344 
frequency of, 344 
gangrenous, 345 
mortality in, 348 
pain in, 347 
perforative, 345 
prognosis of, •"> 17 
symptoms of, 344 
Appendix rermifonnis, anatomical land- 
marks, 344 

655 



656 



INDEX OF SUBJECTS. 



Arteritis umbilicalis, 99 

morbid anatomy of, 100 
prognosis of, 100 
symptoms of, 100 
Arthritis deformans, 545 
rheumatoid, 545 
in vnlvo-vaginitis, 636 
Arthrogryposis, 479 . 
Ascarides lumbricoides, 353 
Ascites, 25 

Asphyxia in cephalhematoma, 116 
in newborn, diagnosis of, 90 
morbid anatomy of, 90 
primary stage of, 90 
prognosis of, 91 
secondary stage of, 90 
symptoms of, 90 
treatment of, 91 

Dew method, 92 
Laborde method, 91 
Marshall-Hall method, 92 
Schultze method, 91 
subsequent to birth, 92 

symptoms of, 92 
Asthma, thymic, 567 
Ataxia, hereditary, 519 
course of, 519 
diagnosis, differential, 520 
prognosis of, 520 
symptoms of, 519 
treatment of, 520 
Atelectasis, convulsions in, 94 
of the lung, 93 

symptoms of, 93 
treatment of, 94 
Athrepsia. See Atrophy. 
Atresia, cellular, of labia, 617 
Atrophy, gastro-intestinal, 325 
etiology of, 325 
morbid anatomy of, 325 
symptoms of, 325 
treatment of, 327 
Auricular-ventricular septum deficiency 

of, 441 
Auto-infection intestinal, 574 

BABINSKI'S reflex, 31, 192 
in tuberculous meningitis, 257 
Bacillus capsulatus aerogenes, 36 

infection in hvpodermo- 
clysis, 323 
diphtheria?, 206 
Bacterial diseases in newborn infants, 17 
Barlow's disease. See Scorbutus. 
Basedow's disease, facial expression in, 21 
Bath, daily, temperature of, 44 
full, 36 
sponge, 35 
Bednar's aphtha?, 46 

in septic infection, 96 
Bell's paralysis, 512 
Binder, body, 44 
Birth, injuries during, 113 



Birth palsies, 114, 509, 510 

clinical symptoms of, 510 
paralyses, head in, 20 
Blennorrhoea, urogenital, 633 
Blindness in pertussis, 204 
Blood in cretinism, 563 
in diphtheria, 211 
in leukaemia, 578 
in measles, 153 
in pertussis, 203 
in pneumonia, 383, 403 
in rachitis, 542 
in scarlet fever, 132 
in simple anaemia, 574 
specific gravity of, 572 

in diarrhoea, 572 
in infectious diseases, 572 
in newly born infant, 572 
in syphilis, 271 
Body, length of, in boys and girls, 56 
Bone-changes in hereditary syphilis, 268 

in scorbutus, 590 
Bones, in cretinism, 564 
diseases of, 595 
of head, injury to, 596 

syphilis of, 596 
rachitis of, 595 
syphilis of, 264, 271, 595 
tuberculosis of, 595 
Botalli, open ductus, 440 
Bowel movements, character of, 57 

number of, 57 
Bowels, condition of, in examination of 

infant or child, 19 
Boys and girls, loss of weight in new- 
born, 53 
weight and height, 56 
Brain abscess in bronchiectasis, 373 
hernia of, 117 
tuberculosis of, 261 
tumors of, 505, 508 
etiology of, 506 
location of, 506 
symptoms of, 506 

dependent on location, 507 
Brandt bath, 36 _ 

Breast feeding, signs of insufficient, 57 
milk, amount taken by infant, 73 
analysis of, 60, 61, 62 
bacteria in, 60 
influence of foods on, 60 
nurse's, toilet of nipple, 46 
Breasts, caking of, 48, 52 
care of, 52 

of newborn infant, 47 
nipples, care of, 52 
Breathing, forms of, 360 
bronchial, 360 
broncho-vesicular, 360 
puerile, 360 
Breck's infant feeder, 89 
Bronchiectasis, abscess of liver in, 373 
amyloid degeneration in, 373 



INDEX OF SUBJECTS. 



657 



Bronchiectasis, brain abscess in, 373 
complication of, 373 
congenital, 371 
coogb in, 372 
course of, 375 
deformity in. .373 
diagnosis of, 373, 374 
dyspnoea in, 373 
emphysema in, 373 
etiolqgy of, 372 

expectoration in. 372 
heart disease in, 373 
laryngeal disease in, 373 
physical >ign> of. 374 

symptoms of, 372 
temperature in, 373 
treatment of, 375 
Bronchitis, acute, 302 

causation of, 3(52 

morbid anatomy of, 362 

physical signs of, 303, 364 

symptoms of. 362 

treatment of, 364 
capillary. 362, 364 
chronic, 366 
fibrinous, 365 

complications of, 366 

diagnosis of. 366 

etiology of, 365 

morbid anatomy of, 365 

physical signs of, -W) 

symptoms of, 365 

treatment of. 366 
and influenza. 1 86 
Bronchopneumonia, atelectasis, 93 
bacteriology of, 392 
cerebral symptoms of, 396 
complications of. 399, 4<H 
course of. 399 
and diarrhoea, 300 
in diphtheria, 215, 219 

treatment of, 234 
etiology of, 391 

fever in, 395 

tro-intestinal tract in, 396 
in measles, 
meningitis in. 399 
morbid anatomy of, 392 
occurrence of, 390 
pericarditis in, 399 
persistent 4<>7 

blood, f<»: 

diagnosis of, 408 

physica] signs of, 108 

symptoms of, 407 

treatment of. 108 

in pertussis, 203, 397 
. phyaiea] signs of. 101, 102 

prognosis of, \n\ 
pulse in, 396 

in scarlet fevei 

in sepsis, 87 
signs mistaken for, 102 
t.» 



Bronchopneumonia, sputum in, 396 

symptoms of, 393 

treatment of, 404, 407 

tympanites in. 396 

in typhoid fever, 398 

in varicella, 398 

vomiting in, 396 
Buhl's disease, 105 

CALCULI, renal, 619 
symptoms of, 619 
treatment of, 619 
urethral, 616 
Qancrum oris, 289 
Caput Buccedaneum, 117 
Carcinoma of kidney, 628 
hematuria in, (529 
of thymus gland, 568 
Cardiac area, conformity of, in children, 
24 
palpation of, 434 
disease, expression in, 21 
lesion in erythema nodosum, 645 
Oaseinogen, 58 
Catalepsy, 483 
Caustic alkali, lesions following ingestion 

of. 221 
Cephalolnematoma, 115, 117, 576 
complications of, 116 
diagnosis of, 116 
occurrence of, 116 
pathogenesis of, 116 
prognosis of, 117 
symptoms of, 115 
Cerebral palsy gait in, 32 
infantile, 508 

diagnosis of, 511 
etiology of, 508 
forms of, 508 
morbid anatomy of, 509 
prognosis of, 512 
symptoms of, 510 
treatment of, 512 
syphilis, hereditary, 272 
Cerebrospinal fluid, 408 
abnormal, ON 

in cerebrospinal meningitis, 469 
in chronic hydrocephalus, 469 
pressure of, 470 

-cdOncnt of. 170 

specific gravity of, 468 

in suppurative menin- 
gitis, 469 

in tuberculous meningitis, 469 

meningitis, 190 
bacteria in, 191 

blood in. 194 

cerebral symptoms in, 192 

choroiditis in, 192 
circulation in. 10 I 
course and prognosis of, 194 

diagnosis of, 195 
endocarditis in. 104 



658 



INDEX OF SUBJECTS. 



Cerebrospinal meningitis, epidemic, 191 

erythema in, 192 

etiology of, 191 

hemiplegia in, 1 94 

intramuscular abscess, 192 

joints in, 192 

morbid anatomy of, 191 

nasal secretion of, 193 

occurrence of, 191 

optic neuritis in, 192 

paralyses in, 194 

reflexes in, 192 

respiration in, 194 

skin in, 192 

sporadic, 191 

symptoms of invasion, 192 

temperature in, 193 

treatment of, 196 

types of cases, 191 
Charcot-Leyden crystals, 334 
Chest, examination of, 22 

exploratory puncture of, 422 
fluid in, diagnosis of, 421 
inspection of, 24 
movements of, 357 
palpation of, 24 
percussion of, 25 
position in examining, 22 
wall, resiliency of, 358 
Cheyne-Stokes respiration, 358 

in cerebrospinal meningitis, 194 

in tuberculous meningitis, 255 
Chicken-pox. See Varicella. 
Childhood, definition of, 17 
Chills, 19 
Chlorosis, 574 

occurrence of, 575 
Cholera infantum, 316 

duration and prognosis of, 320 

hydrencephaloid in, 320 

nephritis in, 320 

occurrence of, 320 

symptoms of, 319 
Chondrodystrophia, 565 
Chorea, cardiac symptoms in, 493 
classification of, 489 
diagnosis of, 494 
disturbances of sensation in, 492 
duration of, 495 
frequency and etiology of, 490 
insaniens, 496 

symptoms of, 497 

treatment of, 498 
laryngeal, 493 
morbid anatomy of, 491 
motor symptoms of, 492 
prognosis of, 495 
and rheumatism, 490, 549 
in scarlet fever, 133 
speech in, 492 
with subcutaneous fibrous nodules, 

491 
symptoms of, 491 



Chorea, temperature in, 494 
treatment of, 495 
urine in, 492 
Choroid, tubercle of, in tuberculous men- 
ingitis, 259 
Choroiditis in cerebrospinal meningitis, 

192 
Chvostek's symptom, 581 

in tuberculous meningitis, 255 
Cirrhosis of liver, 611 

etiology of, 611 
morbid anatomy of, 611 
symptoms of, 611 
Clothing, infant's, 45, 46 
Colic, 25, 312 

causes of, 312 
treatment of, 313 
Colicolitis. See Dysentery. 
Colicystitis, 637 

Colitis contagiosa. See Dysentery. 
Colles' law, 266 
Colon, polypoid tumors in, 27 
Colostrum, composition, 58 
Compress, cold chest, 35 
Congenital heart disease, 437 

classification of, 438 
diagnosis of, 438, 440 
dilatation and hypertrophy 

in, 437 
murmurs in, 437 
syphilis, condyloma, 270 
nasal deformity in, 21 
Conjunctivitis, gonorrhoeal, 635 

in measles, 153 
Conrad's lactobutyrometer, 61 
Constipation, 57, 335 
massage in, 338 
movements in, 336 
symptoms of, 336 
treatment of, cathartics in, 338 
Constitutional disease, morbidity, 18 
Conus, pulmonary artery, stenosis of, 439 
Convulsions, 19, 34 

in atelectasis, 94 
infantile, 472 

diagnosis of, 474 
etiology of, 473 
morbid anatomy of, 473 
prognosis of, 475 
symptoms of, 473 
treatment of, 475 
in pertussis, 204 
in tuberculous meningitis, 254 
Coprolalia, 498 

Cord, umbilical, dressing of, 44 
Cows' milk, bacteria in, 69 
casein of, 65 

coagulation of, 65 
composition of, 64 
fat in, 65 
Cranial bones, indentations of, 113 

syphilis^ of, 273 
Craniorachischisis, 528 



INDEX OF SUBJECTS. 



659 



Craniosehi-is, 528 
Graniotabes, 536, ")0(> 
Cretinism, ansemia in, 574 

blood in, 563 

bones in, 564 

diagnosis o\\ 564 

etiology ot\ 564 

forms of, 560 

morbid anatomy of, 564 

sporadic, 560 

eongenital, 561 

symptoms of, 561 

treatment of, 566 
Cretins, hand of, 563 
Cries hydrocephalique in tuberculous 

meningitis, 259 
Cutis sebaoea, 648 
Cyanosis in atelectasis, 93 

congenital, 437 

in WinckePs disease, 107 
Cystitis, catheterization a cause of, 637 

complications of, 637 

in diphtheria, 637 

etiology of, 637 

forms of, 637 

in scarlet fever. <>37 

treatment of. 637 

in typhoid lever, 637 

DACTYLITIS SYPHILITICA, 271 
Deafnes- in pertussis, 204 
Delire de toucher, 498 
Delorme's operation, 430 
Den ha nit gag, 39, 228 
Dentition. 2. / 

pathology of, 281 
in rachitis, 278 
syphilis in. 278 
ulcer in pertussis, 204 
Dermatitis exfoliativa, 647 
course of, 648 
etiology of, 047 
nature of. 647 
occurrence <>f. 647 
prognosis of. 648 
symptoms of. 647 

treatment of, 6 18 

Dew method in asphyxia, 92 
I riabetes insipidus, 553 

occurrence of, 553 

symptoms of. 554 

treatment of, 555 
mellitus, 552 

etiology <>f. 562 
occurrence of, 552 
symptoms of, ■'>'>- 

Diaper, care of, 10 

Diarrhoea, influenza and. 186 

in scarlel fever. 132 
Dicrotism, normal, 437 
Digestiye tract, frequency of diseaa 

18 
Digital exploration of pharynx, 297 



Dilatation of heart, acute, in scarlet fever, 
152 
and hypertrophy in congenital heart 
disease, 437 
Diphtheria, adenitis in, 221 

affection of accessory sinuses in, 219 
aphtha' in, 22 1 

bacillus, culture of, for diagnosis, 
220 

systemic infection with, 208 
bacteriology of, 207 
blood in, 2il 
cardiac paralysis in, 226 
complications of, 215 

treatment of, 234 
contagion in, 206 
course and duration of, 215 
cystitis in, 637 
diagnosis of, 220 
etiology of, 206 
exanthema in, 219 
feeding in. 226 
frequency of, 18 
gastro-enteritis in, 215 

treatment of, 234 
general infection in, 208 
head posture in, 20 
hemiplegia in, 218 
laryngeal form, 214 

treatment of, 227 
leucocytosis in, 571 
local forms of, 211 

treatment of, 22(1 
malignant forms of, 213 
in measles, 154 
the membrane in, 209 
middle ear in, 211 
morbid anatomy of, 209 
nephritis in, 216 
occurrence of, 206 
otitis in, 598 

paralysis of the heart in, 216 
prognosis of, 222 
prophylaxis of, 222 
pseudobacillus of, 22, 207 
septic forms of, 212 
symptoms of, 211 
thymus gland in, 568 
treatment of, 222 

antitoxin in, dosage of, 223 
eruption, 225 
effect of, 224 
mode of injection of, 224 
time of. 223 
tuberculosis and, 219 

and typhoid fever, 219 

of vulva, 218 

Diphtheritic paralysis, incoordination in, 

Diphtheroid. 220, 235 
diagnosis of. 235 
etiology of, 235 

occurrence of, -'-'> r > 



660 



INDEX OF SUBJECTS. 



Diphtheroid, symptoms and course of, 
235 
treatment of, 235 
Diplegia. See Cerebral palsy. 
Diplococcus intracellulars meningitidis, 

191 
Ductus arteriosus, patent, 440 
murmur in, 441 
physical signs of, 440 
Dungern capsule bacillus, 95 
Dysentery, 329 

and acute intestinal obstruction, 342 
amoebic, 334 
complications of, 333 
course of, 332 
etiology of, 330 
morbid anatomy of, 330 
prognosis of, 333 
prophylaxis of, 333 
treatment of, 333 
Dyspepsia, acute gastric, 309 
course of, 310 
symptoms of, 309 
treatment of, 310 
Dyspnoea, ascites and abdominal tumors 
as a cause of, 362 
in atelectasis, 93 
forms of, 361 
cardiac, 361 
laryngeal, 361 
pulmonary, 361 
in heart disease, 453 
Dysuria, 616 

in measles, 153 

EAK, syphilis of, 265 
Echolalia, 498 
Eczema, etiology of, 641 

squamous, treatment of, 643 
treatment of, 642 
varieties of, 639, 640 
Emphysema in bronchiectasis, 373 
of the lungs, 366 

frequency of, 366 

morbid anatomy of, 366 

physical signs of, 367, 369 

prognosis of, 370 

symptoms of, 367 

treatment of, 370 
in pertussis, 203 
Empyema, 410 

bacteriology of, 412 

bilateral, 430 

deformity after excision of rib, 428 

diagnosis of, 416 

displacement of viscera in, 420 

of pleural fold in, 419 
etiology of, 411 
frequency of, 410 
hemorrhagic, 431 
morbid anatomy of, 411 
perforating, 423 

course of, 424 



Empyema, perforating, prognosis of, 424 
treatment of, 425 
physical signs of, 416, 422 
symptoms of, 415 
treatment of, 426 

of adhesions, 429 
excision of rib, 429 
incision of, 426 
sinus in, 429 

unexpanded lung in, 429 
Enanthema in scarlet fever, 133 
Endocarditis, acute, bacteriology, 442 
course of, 449 
etiology of, 442 
morbid anatomy of, 443 
physical signs of, 447 
prognosis of, 449 
symptoms of, 444 
treatment of, 449 
in cerebrospinal meningitis, 194 
and follicular amygdalitis 301 
healed, 451 
in scarlet fever, 131 
septic or malignant ulcerative, 445 
diagnosis of, 447 
symptoms of, 446 
Endopericarditis in sepsis, 97 
Enema, in constipation, 44 

stimulating, 44 
Enemata, in acute intestinal obstruction, 
344 
in constipation, 338 
rectal, 42 
Enteric catarrh. See Enterocolitis. 
Enteritis follicularis. See Dysentery. 
Enteroclysis, 42 
Enterocolitis. See Dysentery, 
acute and subacute, 328 
etiology of, 328 
morbid anatomy of, 328 
symptoms of, 329 
treatment of, 329 
Enuresis, diagnosis of, 633 
diurna, 632 
nocturna, 632 
symptoms of, 633 
treatment of, 633 
Epiglottis, method of hooking up, in in- 
tubation, 231 
Epilepsy, convulsions in, 487 
diagnosis of, 488 
etiology of, 487 
symptoms of, 487 
treatment of, 488 
Epiphyses, osteomyelitis of, 597 
Epstein's pearls, 96 
Erb's palsy, 113 

etiology of, 518 
prognosis of, 518 
symptoms of, 518 
treatment of, 518 
Erosions, dental, 279 
Erythema exudativum, 645 



JSDEX OF SUBJECTS. 



661 



Erythema multiforme, 645 

treatment of, 646 
nodosum, 551, 645 

cardiac lesion in, 645 
Erythrocytes, 570 
Fstlander's operation, 430 
Exanthema in diphtheria, 219 
Exanthemata, 118 
frequency of, 18 
incubation in, 1 18 
Extubation, 233 

Eye symptoms, in cerebrospinal mening- 
itis, L92 
in late hereditary syphilis, 263 
Byes, nitrate of silver instillation, Crcde 
method, 44 

FACE in parotitis. 20 
symmetry o\\ in adenitis, 20 
Facial palsies in tuberculous meningitis, 
256 
paralysis. See Paralysis, facial. 
during birth, 113 
expression in, 21 
in mastoid disease, 604 
in otitis, 600 
Fatty degeneration, acute, of newborn 
infant, 105 
diagnosis of, 106 
etiology of, K»i> 
morbid anatomy of, 106 
prognosis of. 106 
symptoms of, 106 
treatment of, 106 
Feeding after the sixth month, 81 

amount of daily albumin, fat, and 

carbohydrates, B3 
artificial, 64, 80 
eighteenth to twenty-fourth month, 

B2 
infants and children. I v 
ninth to twelfth month, 81 
quantity of food to be given, 73 
Sick infants and children, 83 
twelfth to eighteenth month. 82 
Filth infection-, frequency of, 18 
Folliculitis abscedens, 6 k 
Fontanelles, closure of, 536 
condition of, 2<» 
in tuberculous meningitis, 254 
Food, infant, composition, 74 

Foot-and-mouth disease of cattle, and 

aphthous stomatitis, 282 

Foramen ovale, open, 1 11 

Fremitus, 

method of ascertaining, -4 
Friedreich's disease, 519 

Fungus, umbilical. 99 

treatment of, 99 
Fnmncnlo-i-, 646 

GIAIT, ataxic :;i 
f limping 



Gangrene of lung, in bronchiectasis, 373 

in bronchopneumonia, 399 
Gastric juice, ferments of, 307 

free 11(4 in, 306 

combined 11(4 in, 306 
spasm, congenital, 313 • 

Gastroenteritis, acute, 316 

classification of, 316 

course and prognosis of, 317 

diagnosis of, 321 

in diphtheria, 215 
treatment of, 234 

morbid anatomy of, 317 

nephritis in, 317, 319 

otitis in, 598 

in pertussis, 204 

prophylaxis of, 321 

role of bacteria in, 317 

symptoms of, 318 

treatment of, 321 
Girls, loss of weight in newborn, 53 

weight and height, 57 
Glandular apparatus in hereditary svph- 

ilis, 268 
Glandular fever, 189 

diagnosis of, 190 

duration of, 190 

etiology of, 189 

symptoms of, 189 

treatment of, 190 
Glottis, spasm of, 484 
Gonorrhoea] urethritis, 636 

ophthalmia in newly born infant, 44 
( iruels, dextrinized, 78 
(xnms, incision of, 281 
( lyrospasm, 498 

HABIT movements, 498 
I hematoma of sternomastoid nmsele, 
115 
I hematuria, 617 

in carcinoma of kidney, 629 

causes of, 617 
Haemoglobin, 571 

in fetus, 571 

in infancy. 572 

in newly born infant, 572 
I hemoglobinuria, causes of, tils 

epidemic in newly born infant, 107 

paroxysmal, 618 

treatment of, 618 
I hemophilia, 5*3 

etiology of. 583 

nature of, 583 

symptoms of. 563 

treatment of, 583 

Elands of nurse, care of. 46 

Head, bones of, injury to, 596 
syphilis of, 596 
examination of, 20 
measurements, 56 
position in Pott's disease, 20 
shape of, 20 



662 



INDEX OF SUBJECTS. 



Head-nodding, 498 
Hearing, 48 
Heart, 433 

apex-beat, 433 
auscultation, 434 
chronic disease of, 450 
etiology of, 450 
frequency of, 450 
physical signs of, 450 
prognosis of, 453 
symptoms of, 453 
treatment of, 454 
congenital disease of, 437 
dilatation of, 466 
in pertussis, 203 
symptoms of, 466 
treatment of, 466 
disease in bronchiectasis, 373 
displacement in pleurisy, 421 
hypertrophy of, 466 
irritable, 451 

paralysis of, in diphtheria, 216 
percussion of, 434 
physical examination of, 433 
position of, 433 
size of, 433 

sounds, character of, 434 
Hemi-ansesthesia in pertussis, 204 
Hemiplegia in cerebrospinal meningitis, 
194 
in diphtheria, 218 
in pertussis, 204 
spastic. See Cerebral palsy. 
Hemorrhage, idiopathic, from umbilicus, 
102 
etiology of, 102 
occurrence of, 102 
symptoms of, 102 
treatment of, 103 
in pertussis, 204 
Hemorrhagic diathesis, 582 
Hernia?, umbilical, 103 

symptoms of, 103 
treatment of, 103 
Herpes labialis in cerebrospinal menin- 
gitis, 192 
of tonsil, 221, 302 
Heubner-Hoffmann mixture, 67 
Hippus in tuberculous meningitis, 255 
Hutchinson's teeth, 278 
Hydremia, 573, 616 

Hydrencephaloid in cholera infantum, 
320 
diagnosis of, 502 
facial expression in, 21 
Hydrocephalus, acute, 500 
course of, 500 
symptoms of, 500 
chronic external, diagnosis of, 502 
symptoms of, 503 
internal, 500 

diagnosis of, 502 
etiology of, 500 



Hydrocephalus, chronic, internal, morbid 
anatomy of, 500 
prognosis of, 502 
symptoms of, 501 
treatment of, 503 

facial expression in, 21 
Hydromyelocele, 529 
Hydronephrosis, 627 
Hydrorhachis, 528 
Hydrotherapy, 34 

in bronchopneumonia, 405 

in lobar pneumonia, 389 

in measles, 157 

in scarlet fever, 138 

in typhoid fever, 178 
Hygiene of infancy and childhood, 44 
Hypertrophic pyloric stenosis. See Py- 
loric stenosis, 313 
Hypodermoclysis, 36 

in acute gastro-enteritis, 323 
Hysteria, 476 

diagnosis of, 478 

disturbances of sensation, 478 

duration of, 479 

etiology of, 476 

motor manifestations in, 477 

psychic or mental, 476 

symptoms of, 476 

treatment of, 479 

TCHTHYOSIS, congenital, 648 
_L symptoms of, 648 

treatment of, 648 
Icterus, catarrhal, 609 
infectious, 609 
neonatorum, 111 
etiology of, 111 
symptoms of, 111 
treatment of, 111 
in the newly born, 110 
Idiocy, amaurotic, 504 

diagnosis of, 505 
etiology of, 504 
morbid anatomy of, 504 
ocular changes in, 505 
spastic symptoms of, 505 
symptoms of, 504 
-with dwarfism, 565 
Mongolian, 565 
Ileocolitis. See Dysentery. 
Ileotyphus. See Typhoid fever. 
Impetigo contagiosa, 640 
Incubators, 85 

indication for use of, 87 
Infancy, definition of, 17 
Infant foods, 77 

mode of holding, for examination, 23 
Infantalism, 565 
dental, 280 # 
Infantile paralysis, gait in, 32 
Infants, premature, 85 
Infarction, uric acid, 619 
Infectious diseases, acute, frequency of, 18 



INDEX OF SUBJECTS. 



663 



Influenza and angina, 186 
and bronchitis. 186 
complications of, 1ST, 189 
and diarrhoea, 186 
etiology o\\ 185 
incubation in, 186 
morbid anatomy of, 185 
and meningitis, 1 ^7 
and nephritis, 188 
and otitis, 188, 598 
and pneumonia, 1ST 
symptoms of, 1 85 
Infract ores in scorbutus, 592 
Intertrigo, 04 1 

treatment, 044 
Intestinal obstruction, acute, 339 
diagnosis of, 342 
enemata in, 343 
frequency of, 340 
hemorrhage in, .'541 
prognosis of, 342 
spontaneous cure of, 343 
symptoms of, 340 
tenesmus in, 341 
treatment of, 343 
tumor in, 341 
vomiting in, 340 
Intestine, bacteria of, 308 

ferments of, 307 
Intramuscular abscess in cerebrospinal 

meningitis, 192 
Intubation, 227 

built-up tubes, 234 
dangers of, 2:;:') 
feeding after, 234 
Intussusception, 339. See Obstruction, 

acute intestinal, 
tnvertin, 308 
Irrigation, rectal, 42 
Irritable heart, 451 

JAMES bottles, 129 
Jaundice, 19, 609 

bacteriology of, 610 

catarrhal, •'»< >'. • 

duration of, 61 1 
morbid anatomy of, 010 
occurrence <>t'. 610 
symptoms of, 610 
treatment of, 61 1 

Joints, affection- of, in varicella, 101 

crepitus, 28 

examination of. 27 

hemorrhage into, 583 
in measles. 153 

mobility 

osteomyelitis of, 597 
in septic infection. 96 

KEB \TITIS, in cerebrospinal mening- 
itis, 192 
Kernig'a symptom , 31, 192 

in tuberculoid meningitis, 257 



Kidney, carcinoma, 628 

diagnosis of, 630 

duration of, 030 

haematuria in, 029 

symptoms of, 029 

urine in, 629 
cysts of, 027 
diseases of, 014 
displaced, 014 
floating, 27, 014 
growths of, treatment of, 031 
new growths of, 027 
palpation of, 014 
sarcoma of, 628 

urine in, 628 
in scarlet fever, 130 
tuberculosis of, 030 
weight, 014 
Koomyss, 80 
Kyphosis, normal, 28 

LA IH A, cellular atresia of, 017 
Laborde's method in asphyxia, 91 
Lactase, 308^ 

Laryngeal disease in bronchiectasis, 373 
Laryngismus stridulus, 484 

complications in, 486 
diagnosis of, 486 
etiology of, 484 
lymphatism with, 581 
morbid anatomy of, 485 
occurrence of, 484 
prognosis of, 486 
symptomatology of, 485 
and the thymus, 568 
treatment of, 486 
Laryngitis, acute catarrhal, 303 
etiology of, 303 
symptoms of, 303 
treatment of, 304 
Laryngospasm and tetanv, 4S2 
Larynx, infantile, 232 

tuberculosis of, 251 
Leucocytes, number in a cubic milli- 
metre, 571 
Leucocythii'inia, 577 
Leucocytosis, digestive, 571 
in diphtheria, 571 
inflammatory, 571 

in lobar pneumonia. 383 

in measles, 571 
in pertussis, 203 

in post-hemorrhagic anaemia, 571 
in pneumonia, 571 
in pseudoleukemia anaemia, 577 
in purpura naemorrhagica, ; ' v 1 
in rheumatism, 571 
in scarlet lever, 132, 571 
in sepsis. 571 
Leucopema, in cachexia, 571 
in malaria, 571 
in tuberculosis, 571 

in typhoid fever. 571 



664 



INDEX OF SUBJECTS. 



Leukaemia, 577 

acute, symptoms of, 579 
blood-changes in, 578 
chronic, symptoms of, 580 
etiology of, 578 
forms of, 578 
lymphatic, 578 
myelogenous, 578 
occurrence of, 578 
Lewi fat analysis, 62 
Lichen scrofulosorum, 238 
Liebig's food, 322 
mixtures, 79 
Lingua geographica, 291 
Lithiasis, 19 

and dysuria, 616 
Liver abscess, 612 

in bronchiectasis, 373 
acute yellow atrophy of, 613 
cirrhosis of, 611 
diseases of, 607 
displacement of, by empyema, 609 

in pleurisy, 420 
enlargement, diagnosis from kidney 

tumors, 609 
enlargement of, 609 
examination of, 607 
fatty degeneration of, 612 

and varicella, 161 
ferments, 307 
palpation of, 607 
percussion of, 607 
phantom tumor of, 608 
in rachitis, 609 
in sepsis, 97 

superficial dulness of, 608 
syphilis of, 612 

hereditary, 272 
late, 265 
Lobar pneumonia mistaken for appendi- 
citis, 347 
Lordosis, normal, 28 
Lumbar puncture, 46.8 

abnormal cerebrospinal fluid, 

468 
in cerebrospinal meningitis, 195 
gross appearances of cerebro- 
spinal fluid, 468 
indications for, 471 
instrument for, 471 
method of, 470 

normal cerebrospinal fluid, 468 
operation of, 470 
place of puncture, 470 
specific gravitv of cerebrospinal 

fluid, 468 
in tuberculous meningitis, 260 
Lung, atelectasis of, 93 

gangrene in scarlet fever, 132 
Lungs, emphysema of, 366 

in hereditary syphilis, 267 
normal limits of, 358 
Lymphadenitis, chronic, 558 



Lymphadenitis, chronic, symptoms of, 558 
treatment of, 559 

retropharyngeal. See Ketropharyn- 
geal abscess, 294 
Lymphatism, 581 
Lymph-nodes, enlargements of, 556 

in glandular fever, 190 

in measles, 153 

of retropharynx, 295 

in scarlet fever, 134 

MACEWEN'S sign in cerebrospinal 
meningitis, 194 
in tuberculous meningitis, 260 
Macroglossia, 291 
Malaria, anaemia in, 572 
Malarial fever, 179 

blood in, 180 
diagnosis of, 182 
etiology of, 180 
morbid anatomy of, 183 
prognosis of, 182 
repeated attacks of, 182 
symptoms of, 181 
treatment of, 183 
Malted foods, 78 
Mania, in scarlet fever, 130 
Marasmus. See Atrophy. 
Mastitis in newborn infants, 48 
Mastoid disease, enlarged lymph-nodes 
in, 603 
facial paralyses in, 604 
pain in, 603 
in scarlet fever, 603 
temperature in, 603 
tumefaction in, 604 
inflammation of, course of, 605 
diagnosis of, 604 
etiology of, 602 
frequency of, 602 
in measles, 154 
otoscopic examination in, 603 
physical signs of, 603 
prophylaxis, 605 
symptoms of, 602 
treatment of, 605 
region, general, 601 
McBurney's point, 347 
Measles, 143 

amaurosis in, 153 

and antitoxin eruption, 156 

blood conditions in, 153 

bronchitis, bronchopneumonia, and 

atelectasis in, 150 
bronchopneumonia in 398 
conjunctivitis in, 153 
definition of, 143 
diagnosis of, 154 
diarrhoea in, 152 
diphtheria in, 150, 154, 219 

treatment of, 158 
and drug eruptions, 156 
dysuria in, 153 



ISDEX OF SUBJECTS. 



665 



Measles, enanthema of, 147 
endocarditis in, 152 
exanthema of, 148 
and syphilis, L56 

heart in, 152 
hemorrhagic, 149 

immunity in, 144 
incubation in, 144 
intestinal complications in, 152 

joints in, L53 

leuoocytosis in, 571 

mastoid inflammation in, 154 

meningitis in, 1 •">."> 

myocarditis in. 152 

nephritic complications and sequela? 

of, 152 
nephritis in, 152 

nose, pharynx, and larynx in, 149 
osteomyelitis in, L53 
otitis in, 154 
photophobia in, loo 
and pertussin loo 
pneumonia in, 151 
prognosis of, 154 
prophylaxis of. 156 
and Rotheln, loo 
and scarlet fever, 155 
sequela? of, 154 
stomatitis in, loo 
symptoms of. 145 
temperature in, 146 
treatment of complications, 157 

general, 156 
tuberculosis in, 152 
Meconium, •">:; 
Meigs' mixture, 66 
Mehena neonatorum, 104 

diagnosis of, li>."> 

morbid anatomy of, 104 

prognosis of, 1<>5 

symptoms <>f. 105 

treatment of, 1<».") 
spurious, 105 
Melancholia in pertussis, 204 

in scarlet fever. 131 
Meningitis, cerebrospinal Set Cerebro- 
spinal meningitis, 
influenza and, 1 ^7 
in measles, 1 ■">•"> 
in pneumonia. 

diagnosis of, 200 
posterior basic, 195 
staphylococcic, 195 
streptococcic, 195 
treatment of, 261 
tuberculous, 252 

Chvostek sym p tom in, 255 

diagnosis of, 258 

duration of. 261 

etiology of, 252 
Kemig's symptom in. 255 
lumbar puncture in. 260 
morbid anatomy of, 252 



Meningitis, tuberculous, occurrence of, 
252 
ordinary type of, 254 
prognosis of, 261 
rapid course of, 25S 
symptoms of, 254 
temper,. Hire in, 25(5 

Trousseau symptom in, 255 
Meningo-encephalocele, 528 
Meningocele spinalis, 529 
Menstruation, effect on breast-milk, 60 

Microdontism, 280 
Miliaria alba, 647 

rubra, 047 
Milk, acidity of, 70 

in breasts of infants, 48 
in breasts of nurse, 50 
human, analysis of fats, 61 
composition of, 58 
excretion of drugs in, 50 
microscopical examination of, 04 
proteids in, 58 
reaction of, 59 
specific gravity of, 50 
variations in daily composition 
of, 59 
modifications of, home. 75 

laboratory, 75 
mother's, insufficient, 51 
raw, in infant feeding. 72 
Mongolian idiocy, palpebral fissure in, 21 
Monoplegia in pertussis, 204 
Morbidity of acute infectious diseases, 18 
in childhood, 18 
diseases of the kidney, IS 
exanthemata, 18 
gastro-enteric diseases, 18 
of newborn, 17 
respiratory diseases, 18 
Morbus maculosus Werlhofii, 584 

Mouth, bacteria, 308 
care of, 40 

in breast-fed infants, 286 
diseases of, 277 
infant, in sleep, 20 
normal, characteristics of, 277 
reaction, secretions of. •"> ,| "> 
toilet, in bottle-fed infant-. 286 

washing of, 45 

Mucous colitis. See Mucous disease. 

di<ea-e, 335 

symptoms of, 336 
treatment of. 

membranes in late syphilis, 265 

Mumps. 10f, 

complications of, 109 

course of. loo 

diagnosis of, 200 

etiology of, loo 

morbid anatomy of, 107 

prognosis of, 200 

submaxillary involvement in, 198 

symptoms of, 197 



666 



INDEX OF SUBJECTS. 



Mumps, treatment of, 200 
Murmurs, arterial, 456 

cardiac, accidental, 455 
characters of, 455 

in congenital heart disease, 437 

venous, 456 
Muscle, atrophy of, 30 

hypertrophy of, 30 

reflex, 30 
Myelocystocele, 529 
Myelomeningocele, 529 
Myocarditis, diagnosis of, 458 

etiology of, 457 

morbid anatomy of, 456 

in scarlet fever, 131 

treatment of, 458 
Myotonia, 483 

NEPHEITIS, acute, 619 
diffuse, 619 
exudative, 619 
parenchymatous, 619 
treatment of, 623 
anasarca in, 622 
in cholera infantum, 320 
chronic diffuse, 624 

symptoms of, 624 
in diphtheria, 215 
influenza and, 188 
in measles, 152 
in pertussis, 203 
in scarlet fever, 130 
uraemia in, 622 
in varicella, 161 
Nerves, morbid anatomv of, in diphtheria, 

210 
Neuritis, multiple, 515 
course of, 516 
diagnosis of, 517 
etiology of, 515 
morbid anatomy of, 515 
sensory disturbances in, 516 
symptoms of, 516 
treatment of, 518 
Newborn infant, asphyxia of, 89 
definition of, 17 
osteomyelitis in, 597 
placing at the breast, 52 
polycythemia in, 570 
Nipples, bottle, care of, 46 
fissures of, 52 
inflamed, 52 
Nodes, mesenteric, enlarged, 26 
Noma, occurrence of, 291 
symptoms of, 290 
treatment of, 291 
Normoblasts, 573 

Nose, intra-uterine deformity of, in hered- 
itary syphilis, 269 
syringing of, 37 
Nursery, temperature of, 45 
Nursing bottle, form of, 72 
at breast, intervals of, 52 



Nursing inefficient, signs of, 53 

infant at breast, contraindications to 
nursing, 51 

intervals of, 53 

period, morbidity of, 18 
Nursings, number of daily, 74 

number of, in twenty-four hours, 53 
Nutans spasmus, 498 
Nutation of head, nystagmus in, 22 
Nystagmus, 22, 498 

in albinism, 22 

in amaurotic idiocy, 22 

in rachitic infants, 22 

OBSTETKICAL palsy, 518 
Ocular symptoms in otitis, 260 
Oculomotor paralysis in pertussis, 204 
(Esophageal stricture due to ingestion of 

alkali, 287 
Omphalitis, 99 
Omphalorrhagia, 101 
Ophthalmia, diphtheritic, 218 
neonatorum, 109 

prognosis of, 110 
treatment of, 110 
Opisthotonos in tetanus, 108 

in tuberculous meningitis, 255 
Optic neuritis in cerebrospinal meningi- 
tis, 192 
Orbital muscles, paralysis of, in cerebro- 
spinal meningitis, 192 
Osteomyelitis, 596 
diagnosis of, 597 

from scorbutus, 597 
from syphilis, 597 
etiology of, 596 
of joints, 597 
in measles, 153 
in newborn infant, 597 

prognosis of, 598 
in scarlet fever, 129, 597 
in septic infection, 96 
symptoms of, 597 
treatment of, 598 
tuberculous, 598 
Otitis, 598 

acute suppurative, 599 
bacteriology of, 598 
in bronchopneumonia, 399 
in cerebrospinal meningitis, 598 
complications of, 601 
course of, 600 
diagnosis of, 601 
in diphtheria, 598 
etiology of, 598 
frequency of, 598 
in gastro-enteritis, 598 
in influenza, 188, 598 
in measles, 154 
media catarrhalis, 599 

purulent, temperature, 600 
and meningitis, diagnosis of, 260 
morbid anatomy of, 599 



INDEX OF SUBJECTS. 



667 



Otitic, and ocular symptoms, 260 
in pertussis, 598 

prognosis of, 601 
in scarlet fever. 1:27. 133, 135 

symptoms oi\ 599 
in typhoid fever, 598 
in varicella, 161 
Oxyuris vermieularis, 354 

PAt'K. cold, 35 
Palpitation in chronic heart disease, 
451 
Palsies, acute, 509 

birth, 114, 509, 510 
prenatal, 509, 510 
Palsy, cerebral, acute, 510 
due to otitis, 514 
facial, 512 

nuclear, facial expression in, 21 
post-natal, 509 
rheumatic, 513 
treatment, 515 
Pancreas in congenital syphilis, 208 

physiological facts. 308 
Paralvsis, acute atrophic, atrophy of mus- 
cle, 522 
course of, 522 
diagnosis of, 523 
etiology of, 520 
morbid anatomy of, 523 
occurrence of, 520 
onset of, 521 
paralysis in, 521 
prognosis of, 522 
Bequelae of, 522 
>yinptoms of, 521 
treatment of, 524 
in diphtheria, 217 

treatment of, 234 
essential, 520 
infantile, 520 

pseudohypertrophic muscular, 525 
complications of, 527 
course of, 526 
diagnosis of, 527 
electrical reaction ofmUSCle 

in, 52<) 
morbid anatomy of, 527 

occurrence and etiology of, 

525 
prognosis of. 527 
reflexes in. 526 
symptoms of. 525 
treatmenl of) 527 
varieties of, 527 
of -oft palate in diphtheria, 221 
Paranephritic 632 
symptoms of, 631 
treatment of. »',:;•_> 
Paraplegia. 8a Cerebral palsy. 

Spastic, -".2 

Parasites, intestinal, 352 
diagnosis of. 352 



Parotitis, epidemic See Mumps. 
Pasteurization, 70 

Pasteurized milk in scorbutus, 589 
Patellar reflex, 30 
Pavor nocturnus, 488 

prognosis of, 489 
symptoms o\\ 489 
treatment of, 489 
Pemphigus neonatorum, (549 

nature and symptoms of, 649 
prognosis of, 650 
treatment of, 050 
in septic infection, 9b 
Peptonized milk, 80 
Percussion of the chest, 25 
Pericardial effusion, amount and diagno- 
sis of, 4b 1 
and pleuritic effusion, differential 
diagnosis, 4b4 
Pericarditis, diagnosis of, 403 
etiology of, 458 

form of dulness of the effusion, 4b2 
forms of, 459 
heart-apex in, 4b 1 
in measles, 152 
morbid anatomy of, 459 
occurrence of, 458 
physical signs of, 4b0 
in pneumonia, 399 
in scarlet fever, 132 
symptoms of, 4b0 
treatment of, 4b4 
Pericardium, adherent. 405 
symptoms, 405 
tuberculosis of, 252 
Perifolliculitis abscedens, 046 
Perinephritic abscess and appendicitis, 347 
Perinephritis, 032 

Periosteum, hemorrhages into, in scorbu- 
tus, 590 
Periostitis, hemorrhagic. See Scorbutus. 
Peritoneum, tuberculosis of. S>'<> Tuber- 
culosis of peritoneum. 
Peritonitis and acute intestinal obstruc- 
tion, 342 
simple chronic, 251 
in vulvovaginitis, 636 
Pertussis, antipyrin in treatment of, 205 
aphasia in, 204 
blindness in, 204 
blood in, 203 
and bronchitis, 202 
bronchopneumonia in. 397 
cardiac dilatation in, 203 
catarrhal stage of, 201 
cocaine in, treatmenl of, 205 

complications of, 203 

convulsions in, 204 
definition of, 200 
diagnosis of, 20 1 
in diphtheria, 219 

emaciation in, 20 I 

emphysema in, 203 



668 



INDEX OF SUBJECTS. 



Pertussis, etiology of, 201 
frequency of, 18 
gastro-enteritis in, 204 
hallucinations in, 204 
hemianesthesia in, 204 
hemiplegia in, 204 
hemorrhages in, 204 
in measles, 153 
melancholia in, 204 
monoplegia in, 204 
morbid anatomy of, 201 
mortality and prognosis of, 204 
nephritis in, 203 
in the newly born infant, 200 
occurrence of, 200 
oculomotor paralysis in, 204 
ozone in, 205 
spasmodic stage of, 202 
symptoms of, 201 
treatment of, bromoform in, 205 
medicinal, 205 
prophylaxis, 204 
urine in, 203 
Peliosis rheumatica, 551, 585 
Phalanges, deformities of, in rachitis, 539 
Phlebitis, umbilical, 101 

treatment of, 101 
Photophobia, 22 

in measles, 153 
Pin worm, 354 
Pleura, tuberculosis of, 252 
Pleural fold displacement of, in pleurisy 
with effusion, 419 
and pericardial effusions, diagnosis of, 
464 
Pleurisy, dry, forms of, 409 
diagnosis of, 410 
etiology of, 409 
prognosis of, 410 
symptoms of, 409 
treatment of, 410 
heart displacement in, 421 
hemorrhagic, 430 
in measles, 152 

with effusion. See Empyema. 
Pleuritis in diphtheria, 215 

in scarlet fever, 132 
Pleuropericardial friction, 463 
Pleuroplegia, 21 

Pneumonia, broncho-. See Bronchopneu- 
monia, 
influenza and, 187 
lobar, crisis of, 378 

bacteriology of, 377 
the blood in, 383 
bradycardia, 382 
cerebral symptoms in, 382 
cough in, 382 
diagnosis of, 388 
dyspnoea in, 382 
etiology of, 377 
hydrotherapy in, 389 
lysis in, 378 



Pneumonia, lobar, morbid anatomy of, 376 
nervous symptoms of, 382 
occurrence of, 375 
physical signs of, 383 
prognosis of, 387 
pseudocrisis in, 378 
remittent temperature, 380 
seat of disease in, 376 
short course of, 385 
subnormal temperature of, 380 
symptoms of, 377 
temperature in, 379 
treatment of, 389 
meningitis in, 399 
osteomyelitis in, 597 
otitis in, 598 
in scarlet fever, 132 
and typhoid fever, 388 
in varicella, 161 
Pneumothorax in pertussis, 204 
Poikilocytosis in ansemia, 573 
Poliomyelitis, anterior, acute, 520 
Polypi, intestinal, 26 
Polyuria, 553 

Posterior basic meningitis, 195 
Pott's disease, 29 

spinal deformity, 538 
Premature infants, 85 

causes of death, 88 
management of, 85 
morbid anatomy of, 89 
prognosis of, 88 
rectal temperature of, 85 
Proctitis, 351 

treatment of, 351 
Progressive muscular atrophv, juvenile 

form, 521 
Pseudoleuksemic ansemia, 575 
Pseudoparalysis in rachitis, 542 
Psoas spasm, 30 
Psvchical derangements in diphtheria, 

218 
Psychoses in pertussis, 204 
Pulmonary artery, stenosis of, 439 
murmur in, 440 
physical signs of, 439 
Pulmonary resonance, 358 
Puncture, exploratory, of the chest, 422 
Purpura hemorrhagica, 584 
course of, 584 
diagnosis of, 585 
etiology of, 584 
treatment of, 585 
Henoch's, 586 
rheumatica, 585 
etiology of, 585 
prognosis of, 585 
symptoms of, 585 
treatment of, 585 
simple, 582 

etiology of, 582 
prognosis of, 582 
symptoms of, 582 



INDEX OF SUBJECTS. 



669 



Purpura, simple, treatment of, 583 
Pyelitis with cystitis. t>:>7 
Pylorus, congenita) stenosis of, 313 
hypertrophic stenosis of, 313 

etiology of, 314 

morbid anatomy of, 314 

prognosis of, 315 

symptoms of, 314 

treatment of, 31.") 

RACHISCIIISIS totalis, 527 
Rachitis, acute. See Scorbutus. 
Rachitis, anaemia in, 540 

blood in, 540, 542 

of bones, 595 

cardiac area in. 24 

and dactylitis, 539 

deformities of extremities, 540 

diagnosis of, 541 

duration of, 541 

etiology of, 533 

expression of face in, 21 

fontanelles in, 536 

head in, 535 

hemorrhagic. See Scorbutus. 

hydrocephalus in, 541 

intestinal disturbances in, 540 

liver in, 540, 609 

morbid anatomy of, 534 

morbidity of, 18 

nervous system in, 541 

occurrence of, 541 

pain in, 537 

pelvic deformities of, 539 

phosphorus in the treatment of, 544 

prognosis of, 542 

relation to scorbutus, 589 

spine in, 538 

spleen in, 540, 569 

symptoms of, 535 

tarda, 542 

treatment of, 543 
Rectum, anatomy of, 349 

exploration of, 27 

polypus of, 351 

diagnosis of, 352 

prognosis of, 352 

treatment of, 352 

Red blood-cells, characters of, 570 

Respirations, normal number of, 357 

in rest and unrest, 20 
Respiratory apncea in retropharyngeal 
abscc— . 2'.»7 

apparatus, frequency of diseases of 
L8 

tnut, diseases of, 357 

Retropharyngeal absceaa acute, 294 

course of. 296 
diagnosis of, 296 
etiology of, 295 
ft >rms <»f. 295 
frequency of, 295 
prognosis of, 297 



Retropharyngeal abscess, acute, symptoms 
of, 296 

treatment of, 297 
characteristic breathing in, 20 
in diphtheria, 216 
in scarlet fever, 129 
Revaccination, 166 
Rheumatic fever, 547 

Rheumatism, acute articular, chorea in, 
549 
endocarditis in, 549 
nature of, 547 
occurrence of, 548 
prognosis of, 550 
symptoms and types of, 548 
treatment of, 550 
and chorea, 490, 549 
gonorrhoea!, 551 
leueocytosis in, 571 
muscular, 551 
Rheumatoid affections, 551 
arthritis, 545 

goitre in, 547 
occurrence of, 545 
prognosis of, 547 
symptoms of, 546 
treatment of, 547 
Rickets, foetal, 565 

scurvy. See Scorbutus. 
Ringworm of the tongue, 291 
Roger, maladie de, 4 '.1 
Rosary of the ribs in rachitis, 536 
Rothein, 140 

complications of, 143 
desquamation in, 142 
diagnosis of, 143 
enanthema of, 142 
exanthema of, 141 
eruption on the genitals in, 143 
lymph-nodes in, 143 
measles and, 155 
occurrence of, 141 
prodromal period of, 141 
spleen in, 143 
temperature curve of, 142 
treatment of, 143 
Round worms, 353 

SALT solution, normal. 36 
Sarcoma of kidney, 628 
diagnosis of, 628 
symptoms of, 628 
Seal p. abscess of, 117 
phlegmon of, 1 17 

Scarlet fever, abscesses in the -kin, 125 

acute dilatation of heart in, 132 
amaurosis in, 130 
anaemia in, 132 

the angina of. 122 
antipyretics in, 138 
antitoxin in, 139 
aphasia in, 131 

bacteriology of, 135 



670 



INDEX OF SUBJECTS. 



Scarlet fever, blood in, 132 

bronchopneumonia in, 398 

buccal mucous membrane in, 123 

chorea in, 133 

cystitis in, 637 

the desquamation of, 126 

diagnosis of, 133 

diarrhoea in, 132 

diphtheria in, 123 

diphtheroid in, 123 

drug eruptions in, diagnosis of, 
134 

the ear, 127 

endocarditis in, 131 

etiology of, 118 

evanescent forms of, 120 

the exanthema or rash, 124 

the eye, 128 

the fever, 1 25 

frequency of, 18 

general course of, 121 

immunity, 119 

incubation of, 119 

joints in, 129 

kidneys in, 130 

leucocytosis in, 571 

lungs in, 132 

complications, treatment of, 
140 

the lymph-nodes in, 128 

malignant cases of, 122 

mania in, 130 

mastoid disease in, 603 

measles and, 155 

melancholia in, 131 

membranous angina, 123 

mode of infection, 119 

the mouth in, 129 

myocarditis in, 131 

necrosis of the nasal cartilages, 
124 

nephritis in, 130, 622 

nervous diseases in, 133 

the nose and nasal passages in,124 

occurrence of, 119 

osteomyelitis in, 597 

otitis, treatment of, 140 

periarticular abscess in, 130 

pleura in, 132 

prognosis of, 134 

prophylaxis of, 137 

rash, pruritus with, 125 

retropharyngeal abscess in, 129 

sequelae of, 132 

stomach and intestines in, 132 

symptoms of, 120 

the tongue in, 124 

treatment of, 136, 138 
of heart, 138 
of joints, 140 
of lymph-nodes, 139 
of nephritis, 139 
of throat and nose, 139 



Scarlet fever, tuberculosis in, 133 

uraemia in, 131 

vomiting in, 132 
Scarlatinal diphtheroid, 222 
nephritis, frequency of, 18 
rheumatism, 129 

prognosis of, 135 
Sclerema adiposum, 112 

diagnosis of, 112 

etiology of, 113 
in cholera infantum, 320 
neonatorum, 112 
Sclerodactylia, 112 
Scleroedema, 112 
Scorbutus, bone changes in, 590 

diagnosed from osteomyelitis, 597 

from purpura, 586 

from syphilis, 593 
disability in, 591 
fracture and infra cture, 592 
infantile, 588 

diagnosis of, 593 

duration of, 592 

etiology of, 589 

history of, 588 

mild cases of, 590 

morbid anatomy of, 590 

nature of the affection, 588 

occurrence of, 588 

prognosis of, 592 

severe cases, 591 

symptoms of, 590 

treatment of, 593 
mortality in, 592 
pain in, 591 
and rachitis, 589 
resorptive temperature in, 592 
Scrofula, 236 

bones and joints in, 240 

course and prognosis of, 240 

diagnosis of, 240 

ears in, 239 

etiologv of, 236 

eye in/239 

forms of, 230 

lymph-nodes in, 239 

morbid anatomy of, 237 

mucous membranes in, 238 

occurrence of, 236 

pyogenic form, morbid anatomy of,. 

237 
skin in, 238 
symptoms of, 238 
treatment of, 241 

tuberculous form, morbid anatomy of,. 
237 
Scurvy, 588 
Seborrhoea capillitii, 641 

treatment of, 645 
Sepsis, diagnosis of, 97 
leucocytosis in, 571 
morbid anatomy of, 97 
in newborn infant, hemorrhages of, 97 



IXDEX OF SUBJECTS. 



671 



Sepsis, prognosis of, 98 

treatment oi\ 98 
Septic infection, 95, 98 

bacteria of, 95 

cryptogenetic, 106 

etiology o\\ !>•"> 

nervous system in, 9(5 

skin in, 96 

symptoms of. 96 

umbilicus in, 96 

Septum defects, auricular-ventricular, 

441 
Sight, 21, 48 

anomalies of, 22 
Sinus in empyema, 429 
Skin, care o\\ 639 

desquamation of, in newborn infant, 

639 
diffuse induration of, in hereditary 
syphilis, 267 
infiltration of, in syphilis, 271 
diphtheria of, 218 
dusting-powder for, 45 
eruptions of, in hereditary syphilis, 

270 
late syphilitic lesions of, 265 
Skull, deformities of, 527 
Soft palate, paralysis of, 221 
Spasm, congenital gastric, 313 
Spasmus nutans, 498 

etiology of, 499 
symptoms of, 499 
treatment of, 499 
Speech in chorea, 492 
Spina bifida, 528 

course of, 530 

diagnosis of, 531 

lumbalis, 531 

occulta, 531 

spherical and elliptical forms of, 

530 
symptoms of, 530 
treatment of, 532 
ventosa, 272 
Spine, anatomical curves, 28 
examination of, 28 
in rachitis, 538 
Spleen in acute leukaemia, 579 
in Buhl's diHease, 106 
in catarrhal jaundice. 569 
in cerebrospinal meningitis, 194 
in chronic gastro-enterjtas, 569 
in cirrhosis of the liver, 569 
gmnmata of, 570 
in heart disease, 
and kidney, tumor- of. 57<) 
palpation of. 
percussion of. 269 
in pseudoleukemia, 569 
in pseudoleukeemic anemia, 570 
in rachitis, 569 
in sepsis, 569 
in syphilis, 569 



Spleen in syphilis, congenital, 268 
late, 265 
in typhoid fever, 569 
Sprue, nature of, 284 
occurrence of, 285 
symptoms of, 2S5 
treatment of, 2S5 
Sputum, 24b 

Starvation, effect of, on breast milk, 60 
Status lymphaticus, 581 
Status praesens, taking of, 20 
Stenosis of pylorus. See Hypertrophic 

pyloric Stenosis. 
Sterilisation ol' milk, disadvantages, 71 
Sterilized milk in scorbutus, 589 
Sterilizer, Arnold's, 71 
Sterility a result of vulvo-vaginitis, (i3t> 
Stethoscope, use of, 22 
Stomacacee. See Ulcerative stomatitis. 
Stomach bacteria, 308 
capacity of, 306 
diphtheria of, 210 
functions and mobility of, 306 
juices, reaction of, 306 
percussion of, 307 
physiological facts, 305 
situation of, 305 
washing of, 39 

indications for, 39 
methods of, 40, 41 
Stomatitis, aphthous, 283 

bacteriology of, 282 
course of, 283 
etiology of, 282 
symptoms of, 282, 283 
gonorrhoea!, 289 

symptoms of, 289 
treatment of, 289 
in measles, 153 
pseudodiphtheritic, 288 

treatment of, 288 
in scarlet fever, 129 
toxic, 285 

treatment of, 287 
ulcerative, 287 

etiology of, 287 
Stools of bottle and breast-fed infants, 74 
infant characters of, 308 

Strabismus in cerebrospinal meningitis, 

192 
Stridor, congenital, 183 
St. Vitus' dance, 189 

Subphrenic abscess, 431 

diagnosis of, 431 
liver dulness in, 608 

treatment of, 431 
Sucking pads, in atrophy, ">_'7 
Sudamina, 45. <>17 
Sydenham's chorea, 189 
Syphilis acquired, 261 

diagnosis of, 262 

etiology of, 261 

prognosis of, 262 



672 



INDEX OF SUBJECTS. 



Syphilis acquired, symptoms of, 262 
anaemia in, 572 
blood in, 271 
of bones, 264, 271, 595 
congenital, 265 

blood in, 271 

bones in, 271 

cerebral symptoms in, 272 

diagnosis of, 273 

diffuse induration of skin in, 271 

eye in, 273 

liver in, 272 

morbid anatomy of, 266, 267, 268 

pancreas in, 268 

prognosis of, 274 

symptoms of, 268 

treatment of, 274, 276 
of the ear, 265 
hereditary, bone-changes in, 268 

glandular apparatus in, 268 

late, 263 

bone lesions of, 264 

eye lesions of, 263 
liver in, 609 
thymus gland in, 568 
in wet nurse, 50 
Syringe, nasal, 37 
Syringomyelocele, 529 

TACHE cerebrale in cerebrospinal men- 
ingitis, 192 
Tachycardia in diphtheria, 217 
Taenia, 354 

Bothriocephalus latus, 355 

elliptica, 354 

mediocanellata, 355 

solium, 354 
Tapeworm, 354 
Tay-Kingdon spot, 32 
Teeth, erosions of, 279 
Temperature, children, 47 

infant's, mode of taking, 46 

of the newborn infant, 46 
Tenesmus in acute, intestinal obstruction, 

341 
Terrors, night, 488 
Tetanilla, 479 

Tetanus neonatorum, duration of, 109 
prognosis of, 109 
treatment of, 109 

of the newborn, 108 
Tetany, 479 

diagnosis of, 482 

duration of, 481 

etiology of, 479 

forms and frequency of, 479 

morbid anatomy of, 479 

mortality of, 482 

muscular contractures of, 480 

prognosis of, 482 

symptoms of, 480 
Tetany, treatment of, 482 
Threadworms, 354 



Thrush. See Sprue. 

Thymus gland, abnormal state of, 567 

carcinoma of, 568 

diphtheria of, 568 

hemorrhages in, 568 

hypertrophy of, 567 

percussion of, 567 

sudden death with enlarged thymus, 
581 

syphilis of, 568 

weight of, 567 
Thyroid gland, diseases of, 559 
Tic, forms of, 498 
Titubation, cerebellar, 32 
Tongue, desquamation of, 293 

diseases of, 291 

ringworm of, 293 

swallowing, 293 

treatment of, 294 

tie, 294 

treatment of, 294 

wandering rash of, 291 
etiology of, 292 
symptoms of, 292 
treatment of, 293 
Tonsillitis, otitis in, 598 
Tonsils, herpes of, 302 
Torticollis, 20 

Toxins, action in scorbutus, 589 
Treatment of adenitis, acute, 558 

of amygdalitis, acute follicular, 302 

of ani, prolapsus, 349 

of aphthae, Bednar's, 284 

of asphyxia in the newborn infant, 
91 

of atelectasis, 94 

of bronchiectasis, 373 

of bronchopneumonia, 404, 407 
in diphtheria, 234 
of persistent, 408 

of bronchitis, acute, 364 
fibrinous, 366 

of cholera infantum, 321 

of chorea insaniens, 498 

of colic, 313 

of cretinism, 564 

of cystitis, 637 

of dermatitis exfoliativa, 647 

of diabetes insipidus. 555 

of dilatation of heart, 466 

of diphtheroid, 235 

of dysentery, 329 

of dyspepsia, acute gastric, 309 

of eczema, 642 

squamous, 643 

of emphysema of lungs, 370 

of empyema, 426 
perforating, 425 

of endocarditis, acute, 449 

of epilepsy, 488 

of Erb's palsy, 518 

of erythema multiform, 645 

of facial palsy, 515 



INDEX OF SUBJECTS. 



673 



Treatment of tatty degeneration, acute, 
in the newborn, 106 

of fissure of anus, 350 

of gastroenteritis, 321 
in diphtheria, 234 

of gastrointestinal atrophy, 327 

of glandular fever, 190 

of gonorrhoea! stomatitis, 289 

of haemophilia, 583 

of heart disease, chronic, 454 

of hereditary ataxia, 520 

of hydrocephalus, chronic internal, 
503 

of hysteria, 479 

of ichthyosis, 648 

of icterus neonatorum, 111 

of idiopathic hemorrhage from um- 
bilicus, 103 

of infantile cerebral palsy, 512 
convulsions, 475 
scorbutus, 593 

of inflammation of the mastoid proc- 
605 

of intertrigo, 644 

of intestinal obstruction, 343 

of jaundice, 611 

of laryngismus stridulus, 486 

of laryngitis, acute catarrhal, 304 

of lobar pneumonia, 389 

of lymphadenitis, chronic, 559 

of melaena neonatorum, 104 

of malarial fever, 183 

of multiple neuritis, 518 

of mumps. 2< 10 

of myocarditis, 458 

of nephritis, acute parenchymatous, 
623 

of noma, 291 

of ophthalmia neonatorum, 110 

of osteomyelitis, 598 

of paralysis acute atrophic, 524 
in diphtheria, 234 
pseudohypertrophic muscular, 
527 

of paranephritis, 632 

of pavor nocturnus, 489 

of pemphigus neonatorum, 649 

of pericarditis 404 

of pertussis, 204, 205 

of pleurisy, dry, 410 

of proctitis, 351 

of pseudodiphtheritic stomatitis, 288 

of pseudoleukemia anaemia, 576 

of pulmonary tuberculosis, 217 

of purpura hemorrhagica, 

rheumatica. - 

simple, 583 
of rachitis, 5 13 

•tal polypi, 

Of n .ial calculi. 619 

of retropharyngeal abscess, acute, 297 
of rheumatism, acnte articular, 550 
of rheumatoid arthritis, 545 

43 



Treatment o\' rotheln, 143 
of scrofula, 241 
of sepsis, 98 
of spina bifida, 532 
o\' sprue. 285 

of subphrenic abscess, 431 
of syphilis, congenital, 274, 276 
of tetanus neonatorum, 109 
of tetany, 482 
of tongue-swallowing, 29 
of tongue-tie, 294 
of toxic stomatitis, 287 
of tuberculosis of peritoneum, 251 
of tuberculous meningitis, 261 
of tympanites, 513 • 
of umbilical fungus, 99 

hernia, 103 

phlebitis, 101 
of varicella, 162 
of vulvovaginitis, 636 
of wandering rash of tongue, 293 
Trismus neonatorum, 108 
Trousseau's phenomenon, 581 

in tuberculous meningitis, 255 
Tubercle, solitary, of brain. 261 
Tuberculous meningitis, Babinski's reflex 

in, 257 
Tuberculosis, abdominal, 252 
anaemia in, 572 
avenues of infection, 242 

cows' milk, 242 

intestinal canal, 242 

mother's milk, 242 

placental, 242 

ritual circumcision, 242 

through wounds, 242 
of bones, 595 
of brain, 261 
and diphtheria, 219 
etiology of, 241 
frequency of, 243 
of kidney, 630 
of larynx, 251 
morbid anatomy of, 244 
of peritoneum, 247 

adhesions in, 250 

constipation in, 248 

course of, 251 

diagnosis of, 250 

etiology of, 217 

liver in, 249 

miliary nodular adhesive form, 
247* 

morbid anatomy of, 247 

occurrence of, 2 17 

pain in, 2 18 

physical signs of, 249 

sp'cen in. 2 19 

symptoms of, 2 i v 
temperature in, 248 

treatment of, 251 
vomiting in, 249 
pulmonary, 2 13 



674 



INDEX OF SUBJECTS. 



Tuberculosis, pulmonary, course of, 246 
diagnosis of, 246 
haemoptysis in, 246 
localization of, 244 
symptoms of, 245 
temperature in, 246 
treatment of, 247 
in scarlet fever, 133 
statistics, 242 
in the wet nurse, 50 
Tuberculous meningitis. See Meningitis, 
choroid, tubercle of, 259 
cries, hydrocephalique in, 257 
facial palsies in, 256 
hippus in, 255 
vomiting in, 254 
osteomyelitis, 598 
Tubes for intubation, retained, 233 
Tumor in acute intestinal obstruction, 341 
contour of abdomen in tumor, 26 
of kidney and spleen, 590 
polypoid, of the gut, 27 
Tympanites, 313 

in bronchopneumonia, 390 
treatment, 313 
Tympanitic distention, in intestinal per- 
foration^ 26 
in peritonitis, 26 
in typhoid fever, 26 
Tympanum spontaneous rupture of, 600 
Typhoid fever, 166 

blood in, 173 

bronchopneumonia in, 398 
cerebral invasion in, 168 
complications of, 174 
cystitis in, 637 
Diazo reaction in, 176 
diet in, 178 
and diphtheria, 219 
enlarged spleen in, 170 
foetal, 167 
frequency, 166 
heart in, 173 
hemorrhages in, 172 
hydrotherapy in, 178 
infantile, 167, 169, 170 
lungs in, 173 
morbid anatomy of, 167 
nervous symptoms of, 173 
occurrence of, 166 
otitis in, 173, 598 
parotitis in, 173 
petechia?, 170 

pneumonic invasion in, 168 
prognosis of, 177 
relapses in, 174 
roseola of, 170 
sequelae, skin, 174 
symptoms of, 168 
treatment of, 178 
alcohol in, 178 
heart in, 178 
hemorrhages, 178 



Typhoid fever, ulcerations of the gut in, 
167 
variety of cases, 168 
Widal reaction in, 176 

Typhoidal ulcer, hemorrhage from, 343 

UMBILICUS, diseases of, 98 
fungus of, 99 

hemorrhage from, 101 

infection in the newborn infant, mor- 
bidity, 17 

in septic infection, 96 
Uraemia in nephritis, 622, 623 

in scarlet fever, 131 
Urethritis, 636 

gonorrhceal, 636 

simple, 636 
Urine, 53, 614 

in carcinoma of kidney, 629 

in chorea, 492 

discolorations of, 19 

indican in, 615 

in lithiasis, 19 

in pertussis, 203 

quantity of, 615 

reaction in cystitis, 637 

in sarcoma of kidney, 628 
Urogenital blennorrhea, 633 

TTACCINATION, 162 
V age of, 163 

complications of, 165 
course of, 164 
eruptions in, 166 

bullous, 166 

erythematous, 166 

morbilliform, 166 

pemphigoid, 166 

pustular, 166 ' 

scarlatinoid, 166 

urticarial, 166 
etiology of, 167 
fever in, 164 

and hemorrhagic diathesis, 163 
human virus, 163 
inoculation of the eye, 166 
lymph of, 164 
mode of, 163 
osteomyelitis in, 165 
sepsis in, 165 
tetanus in, 165 
Vaccinia, generalized, 165 
Varicella, bronchopneumonia in, 398 
bullosa, 162 

and cardiac hypertrophy and dilata- 
tion, 161 
complications of, 161 
definition of, 159 
diagnosis of, 161 
enanthema of, 160 
exanthema of, 159 
and fatty liver, 161 
gangrene of the skin in, 161 



INDEX OF SUBJECTS. 



675 



Varicella, incubation of, 159 
joint-affections in, 161 
nephritis in, 161 
otitis in. 598 
prognosis of, 162 
rheumatoid affections in, 161 
symptoms of. 159 
temperature in, 160 
treatment oi, 1 1>— 

and variola, 161 
and varioloid, 161 
Ventricle, left, marking out dulness of, 

435 
Ventricular septum, congenital deficiency, 

111 
Vesiculotympanitic resonance in atelecta- 
ses. 93 
Vincent's spirillum, '287 
Viscera, displacement of, in pleuritic effu- 
sion, 4'20 
Vomiting, forms of, 19, 311 
habitual, 310 
in scarlet fever, 132 
in tuberculous meningitis 254 
ushering in illness, 19 
Vulva, diphtheria of, 218 
Vulvovaginitis, 633 

arthritis in, 636 

course and complications of, 636 
in diphtheria, treatment of, 234 
etiologv of, 634 



Vulvovaginitis, forms of, 633, 634 
symptoms of, 635 

treatment of, 636 

WALK, spastic, 32 
Weaning 1> roast-fed infants, 81 
Weight, average, of infants and children, 
55 
curve of loss of weight in the new- 
born infant, 54 
daily increase of, 53, 55, 66 
loss in first three days, 53 
normal daily increase, curve of, 55 
Weil's disease, 610 
Wet nurse, mental state of, 50 

milk examination of, 50 
quality of milk, 50 
quantity of milk, 50 
selection of, 49 
age of, 49 
breasts of, 49 
examination of, 49 
nipple, of breasts, 1<> 
Whey, method of milk dilution, 68 

proteids, 59 
Wnite blood cells, 571 
Whooping-cough. See Pertussis. 
Woodward's buret for proteids, 63 
Worms, round, 353 
tape, 354 
thread, 354 



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9E P 1 6 1902 



SEP 16 1902 

1 COPY DEL, TOCAT.Div, 
SEP. 16 J902 



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